Care plan failures
Care plans not accurately reflecting individual needs or care provided, and ineffective systems for quality assurance and continuous improvement.
39 items
1 source
10 inquiries
Source spread
Where this theme appears
Care plan failures has been flagged across 1 independent accountability source:
39 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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 (39)
120 — Interviewers involved in care decisions
Recommendation: Interviewers should be involved in decisions relating to the care of the children while they are in places of safety and the extent of their involvement should be defined (17.60).
Unknown
R6 — Named person approval for transfers
Recommendation: The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring to a new environment within or external to the Trust in which they are cared for. This approval …
No response yet
R5 — Named person for care plans
Recommendation: Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the discussion with the family and the discussion with any relevant …
No response yet
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
LAMI-64 — Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Unknown
R16 — Missed care incident reporting
Recommendation: If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
No response yet
R15 — Independent care plan reviews
Recommendation: Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be …
No response yet
R12 — Person-centred care plans with family involvement
Recommendation: Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families should be actively involved in identifying needs. Resulting care plans …
No response yet
COVID-M3.9 — Standardised Advance Care Planning
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for …
Words of: UK government (Department of Health and Social Care), UK government response to the Covid-19 Inquiry Module 3 report (CP 1664), 14 September 2026
Gov response: For the reasons set out above, while we will continue to take action to improve outcomes, the government does not specifically intend to introduce, at this time, a standard process across the UK and the …
Not accepted
WATE-(38) — Extend local authority duty to provide parental-level support for care leavers
Recommendation: The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so …
Unknown
WATE-(37) — Prepare and periodically review leaving care plans for all looked after children
Recommendation: A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for …
Unknown
WATE-(34) — Designate social worker responsible for care plan implementation and child supervision
Recommendation: An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Unknown
R30 — Fluid balance monitoring
Recommendation: Health Boards should ensure that where patients require fluid monitoring as part of their clinical care, nursing staff complete fluid balance charts as accurately as possible and sign them off at the end of each 24-hour period.
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R27 — Positional change records
Recommendation: Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent. Compliance should be monitored by a system of audit.
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R26 — Wound documentation
Recommendation: Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance, including the cause, grade, size and colour of …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R24 — TVN instructions recorded
Recommendation: Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given for management of the patient.
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R22 — Relative discussions recorded
Recommendation: Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient’s continuing care is recorded in the patient’s notes to ensure that those caring for the …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R18 — Care planning system
Recommendation: Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff. Where appropriate they should introduce pro forma care plans to assist nurses with care …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
99 — Agreement terms available to foster carers
Recommendation: Where children are placed with foster carers belonging to another local authority, a copy of the terms of the agreement between the two authorities regarding the placement should be available to the foster carer so that lines of support and …
Unknown
98 — Keep foster carers informed
Recommendation: Foster carers should be kept informed of any developments regarding any child in their care and of any course of action being taken with the child (17.35).
Unknown
97 — Written report for foster carers
Recommendation: Foster carers should be given a written report at the time when the child is placed, or as soon as practicable thereafter, with as much personal information about the child as possible (17.34).
Unknown
67 — Information for the child's carer
Recommendation: The fullest possible information about the background of the child should be made available to the child’s carer together with such administrative detail as the carer will require for the well-being of the child (16.41).
Unknown
3 — Bereavement care
Recommendation: The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
Words of: Yvette Cooper, Secretary of State for Health and Social Care, oral statement to the House of Commons, 15 September 2026 (text as published on GOV.UK)
Gov response: And I agree with the report that, when the very worst happens and parents face bereavement, they need to be supported to the best of our ability. The report recommends the national bereavement care pathway …
Accepted
In progress
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
WATE-(40) — Develop key indicators to monitor compliance with safeguards for looked after children
Recommendation: Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:34, 62(i) (a) the allocation of a designated social worker to each looked after child; (b) compliance with fostering and placement regulations; (c) statutory review …
Unknown
WATE-(39) — Require fostering services to monitor, analyse, and report placement breakdowns periodically
Recommendation: Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director …
Unknown
WATE-(36) — Provide facilities and encourage acquisition of independent living skills in care settings
Recommendation: The daily regime in residential establishments and foster homes should encourage and provide facilities for the acquisition of skills necessary for independent living.
Unknown
R39 — DNAR decision awareness
Recommendation: Health Boards should ensure that medical and nursing staff are aware that a DNAR decision is an important aspect of care. The decision should involve the patient where possible, nursing staff, the consultant in charge and, where appropriate, relatives. The …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
WATE-(35) — Ensure foster carers receive continuing support and access to specialist services
Recommendation: Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us"919.
Unknown
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
F236 — Identification of who is responsible for the patient
Recommendation: Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who is in overall charge of a patient's care.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. In his speech on patient safety on 21 June 2013, the Secretary of State for Health signalled his support for the practice of hospitals identifying a named consultant who is responsible for a patient’s …
Accepted
In progress
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
WATE-(12) — Safeguard field social worker's responsibilities for placement supervision and care planning
Recommendation: Any arrangements made for the provision of residential care or fostering services should expressly safeguard the field social worker's continuing responsibilities for supervision of the placement and care planning.
Unknown
IBI-10a(iv) — Thalassaemia Society Support
Recommendation: Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: NHS England has successfully established a comprehensive programme of work to prioritise reduction of clinical risk, increase support and care in the community, digitise care plans and step up prevention activities following their review of …
Accepted in part
IBI-9d — Haemophilia Centre Resources
Recommendation: The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: Recommendation 9d: The need to develop and strengthen multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders to improve patient care and support standardisation is supported by the clinical …
Accepted in part
In progress
IBI-2c — Community Support Events
Recommendation: There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
In progress