Chronic healthcare staff shortages
Persistent and unaddressed staff shortages in hospitals and care settings, leading to compromised patient care and burnout.
833 items
14 sources
5 inquiries
Source spread
Where this theme appears
Chronic healthcare staff shortages has been flagged across 14 independent accountability sources:
16 inquiry recs
275 PFD reports
266 committee recs
53 CQC actions
1 HMICFRS rec
9 PPO recs
6 NAO recs
1 PHSO rec
99 IMB reports
61 IMB recs
1 detention investigation rec
3 PHSO decisions
39 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 (16)
R36 — Medical staffing levels
Recommendation: Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high-quality care.
Gov response: Section 4.1 of the Scottish Government's response addresses the need for appropriate levels of medical staff to provide safe, high-quality care. It states a full commitment to planning an NHS workforce that delivers high-quality services, …
Accepted
MAI-156 — Ambulance Liaison Officer resourcing
Recommendation: The Home Office, the Department of Health and Social Care and the National Ambulance Resilience Unit should consider how to ensure that the role of an Ambulance Liaison Officer is properly resourced and also whether venue operators should fund the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-148 — LRF staffing and resources
Recommendation: The Home Office should consider, together with local resilience forums, how they are to have sufficient staff and resources to enable them to function effectively.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-86 — Arena healthcare provider staffing requirements
Recommendation: SMG should ensure that the healthcare service provider at the Arena has adequate staffing and skill levels for every event at that location.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-78 — Review NWAS Tactical Advisor numbers
Recommendation: North West Ambulance Service should review the number of Tactical Advisors and National Interagency Liaison Officers it has, and whether the number of such specialists, both generally and on call, should be increased.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-47 — Sufficient resources for operational planning
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should work together to put in place robust systems, policies and guidance to ensure that all police services have sufficient resources dedicated …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-44 — Ambulance trusts submit resource recommendations
Recommendation: Having carried out that review, the trusts should make recommendations to their NHS commissioners about the additional and/or different resources they require in order to ensure that they are able to respond effectively to a mass casualty incident in the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-25 — Review embedding doctors with firearms teams
Recommendation: Counter Terrorism Policing Headquarters should review the evidence heard during the Inquiry, including that heard in restricted sessions, to consider the advantages and disadvantages of embedding doctors with some police firearms teams, and how, if that is advantageous, it could …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-10 — Resolve paramedic-driver shortage in mass casualties
Recommendation: A significant issue in a mass casualty situation is that all of those paramedics who have arrived in ambulances may be required for the treatment of casualties, so that no paramedic is available to drive patients to hospital. The Department …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-8 — Review mass casualty response capacity
Recommendation: Ambulance service trusts should review their capacity to respond to a mass casualty incident. That should include an assessment of whether they have an adequate number of trained specialist personnel to respond effectively to a mass casualty incident.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
IBI-7c — Transfusion Laboratory Staffing
Recommendation: Transfusion laboratories: Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.
Gov response: UK Government Work is ongoing to determine the current status of transfusion staffing, reviewing best practice from other areas including nursing, and developing an evidence base to inform minimum staffing level standards. The data for …
Accepted in Part
No update 2+ yrs
SHI-8 — IPC role specifications and staffing levels
Recommendation: I accordingly recommend that priority be given to protecting scarce IPC resources. With that objective in view, what is expected of consideration and advice from individual disciplines at various stages of a project should be made clear. Job and role …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: The Scottish Government has published role descriptors for IPC staff and is engaging closely with NHS …
Accepted
In progress
8 — Develop recruitment and retention strategy
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. This should include, but not be limited to, seeking links …
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 …
Accepted
IBI-7d — Training in Transfusion Medicine
Recommendation: Training in Transfusion Medicine: That those bodies concerned with undergraduate and postgraduate training across the UK of those people who are, or intend to be, working in the NHS ensure that they are adequately trained in transfusion, that the standards …
Gov response: UK Government The stakeholder group, including a range of professional and statutory bodies, have been working together to review and propose educational and training requirements. The group is currently collating patient safety e-learning material to …
Accepted in Part
No update 2+ yrs
20 — National review of maternity care in challenging circumstances
Recommendation: There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should identify the requirements to sustain safe services under these conditions. …
Gov response: 7. We accept this recommendation. A review of maternity care, which will also consider neonatal care and paediatrics in the context of maternity care, is underway. 8. In its report to Cumbria Clinical Commissioning Group, …
Accepted
21 — Consider extending review to other rural services
Recommendation: The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider the wisdom of extending the review of requirements to sustain …
Gov response: 11. We accept this recommendation in principle. NHS England are establishing Vanguard sites to explore how new models of care can address the challenges faced by services that are rural, geographically isolated or difficult to …
Accepted
PFD Reports (275) — showing 50 strongest matches
Jordan Buckton
Concerns: Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Overdue
Luna Lesko
Concerns: Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal and infant deaths.
Response (Lewisham Greenwich NHS Trust): The hospital plans to relocate elective lists to the main theatre unit by the end of January 2014, which would free up the obstetric unit theatre for emergencies and allow …
Overdue
Jack William Payton
Concerns: Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.
Response (Avon and Somerset Police): The police are commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to commence in January 2014, with recommendations to be considered at Force level.
Responded
William Joseph Wilkinson
Concerns: Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.
Overdue
Grace Mary Bates
Concerns: The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Response: A business case for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week …
Response: The Secretary of State for Health acknowledges the coroner's concerns regarding diabetes management at Barnet Hospital and refers to existing NICE quality standards and NHS England initiatives for improving patient …
Responded
Barry James Lewis
Concerns: Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate night staffing.
Response (The Pennine Acute Hospitals NHS Trust): The hospital updated emergency airway packs in A&E, ensuring availability of 'large' instruments. The role of night nurse practitioners was reviewed to ensure involvement in direct care of critically ill …
Responded
Edna Elsie Mary Eden
Concerns: Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Response (Heatherwood Wexham Park Hospital NHS Trust): The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage …
Responded
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Overdue
Barry Dillion
Concerns: Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Overdue
Neil Carter
Concerns: There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Response (CQC): The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat …
Response (Priory Group): The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring …
Responded
Lorna Cullen
Concerns: The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
Overdue
Christopher Williams
Concerns: A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Overdue
Robert Jones
Concerns: CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Response: The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will …
Responded
Phyllis Barnes
Concerns: A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.
Overdue
William Winter
Concerns: Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.
Overdue
Frederick Hall
Concerns: Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.
Overdue
Sari Keen
Concerns: Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.
Response (Luton Dunstable University Hospital): Luton & Dunstable University Hospital has increased night nursing staff on ward 22 following a staffing review. The hospital is evaluating current training for nurses and doctors, and will present …
Responded
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
Dayani Chauhan-Ahmed
Concerns: Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
Response (University Hospital of Leicester NHS Trust): The trust plans to implement several changes, including a proforma for communications during labour, reinforcement of the escalation policy, consultant presence at the LRI, and an annual emergency drill to …
Responded
Henry Marsh
Concerns: The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
Response (Department of Health): The Department of Health acknowledges the concerns about the Home Treatment Team's caseload and refers the Coroner to existing national guidance and resources for Crisis Home Treatment Teams. NHS England …
Responded
Christopher Royal
Concerns: The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively long shifts.
Response (Royal 2014 0354): Following a review of observation policies, the organisation issued a new policy to nursing staff and created a new record sheet for nursing staff. The organisation also developed a more …
Responded
Iris Grimwood
Concerns: Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
Overdue
Thomas Taylor
Concerns: The ward lacked clear leadership and support, there was no protocol for lost notes and drug charts, and there seemed to be no well-understood protocol when the patient refused a blood sugar check.
Overdue
Yohannes Kidane
Concerns: Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.
Response (HM Prison and Probation Service): NOMS reviewed the night staffing level for HMP Birmingham and found it acceptable, noting G4S's deployment of a Prison Custody Officer. They state that the Night Orderly Officer arranges cover …
Response (Birmingham Solihull NHS): The Trust has liaised with Birmingham Community Healthcare Trust and G4S to address staffing concerns and is considering options for staff breaks, including administrative duty sharing. They are engaging the …
Responded
Anne Sandever
Concerns: A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, with no adequate hospital investigation following.
Response: The Trust conducted an investigation and implemented a Trust-wide action plan, including spot checks on wards, a specific training program for recognizing deteriorating patients, and ensuring effective communication. They have …
Responded
Joyce Nelson
Concerns: Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, led to misdiagnosis and potential unsafe discharge.
Overdue
Timothy Cowen
Concerns: New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.
Overdue
Mary Fenton
Concerns: The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack of facilities for echocardiograms after hours, shortages of Isoprenaline, and failures in assessing the patient's mental capacity and obtaining consent to treatment.
Response (Department of Health): The Department of Health acknowledges the concerns about shortages of Isoprenaline and outlines the complexity of pharmaceutical supply chains. They note that Isoprenaline injection is unlicensed in the UK, but …
Response (Tameside Hospital): The trust has updated its DNACPR policy, stressed the importance of communication, reminded clinicians of relevant policies, and advised them to seek refresher training; cardiology staff have been instructed by …
Responded
Betty Smith
Concerns: Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.
Overdue
Thomas Jenkins
Concerns: Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and an overstretched regional TVN service, led to delayed ulcer assessment.
Overdue
Elizabeth Leah
Concerns: Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a broken leg being advised to take a taxi to the hospital. Systemic issues were exacerbated by A&E delays and bed blocking.
Response (Department of Health): NWAS has increased staffing levels in control rooms and on the road, and is developing Advanced Community Paramedic roles. They are also increasing the use of volunteer services and have …
Responded
Laura Hill
Concerns: There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs regarding Section 136 procedures, absconding, and powers of detention.
Response: The Health Board has provided transition guidelines between Child and Adolescent and Adult Mental Health teams since January 2013, enhanced training in personality disorder management (including Dialectical Behavioural Therapy), and …
Responded
Peter Wright
Concerns: Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the hospital lacks adequate out-of-hours doctor cover, relying on paramedics.
Response (South Staffordshire Shropshire Healthcare NHS Trust1): The Trust undertakes nurse staffing establishment reviews every six months, using quality metrics and workload calculators. They also provide basic life support training to medical and nursing staff and have …
Responded
Elizabeth Cox
Concerns: Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due to increased workloads.
Response (Sherwood Forest Hospital): The Trust is implementing a new staffing model on surgical wards with 5 RNs and 2 HCAs on days, and 3 RNs and 1 HCA on nights. Medical wards will …
Responded
Elsie Hayward
Concerns: Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.
Response (Cardiff Vale University Health Board): Cardiff Vale University Health Board has already undertaken actions including ward-level board rounds, safety briefings, MDT meetings, disciplinary investigation of a nurse, and staff retraining, following an internal investigation and …
Responded
Sabrina Stevenson
Concerns: Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.
Response (College of Paramedics): The College of Paramedics commits to writing to NHS ambulance services and HEIs to offer assistance in recruiting paramedics, advising them of revised Paramedic Curriculum Guidance. It will also advise …
Response (London Ambulance Service): London Ambulance Service secured additional investment of £27.2m to improve response times, increase staffing, and improve productivity and are on track to recruit 850 staff in 2015/16. The LAS has …
Response (NHS England1): NHS England details actions taken with the LAS, including weekly performance reviews, additional funding of £27.2m for 2015/16 to increase staffing and capacity, and improve ambulance response times, with a …
Responded
Olive Nugent
Concerns: Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Overdue
Paul Murray
Concerns: Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Response (Department of Health): The London Ambulance Service carried out a serious incident investigation, resulting in plans to increase capacity through its modernisation programme, implementation of 'Intelligent Conveyance', consideration of a process for clinical …
Responded
Barbara Patterson
Concerns: The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Response (Department of Health): NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of …
Response (CQC): The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance …
Response (North East Ambulance Service NHS Trust): The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Responded
John Bartle
Concerns: Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.
Overdue
Stanley Oliver
Concerns: The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying this as a risk.
Response (S Oliver): Salford Royal NHS Foundation Trust plans to develop a 7-day consultant-level non-vascular intervention rota by April 2016. In the short term they will use an ad hoc service with support …
Response (Department of Health): The Department of Health commissioned the Centre for Workforce Intelligence to gather evidence on possible shortage occupations, leading to radiologists being added to the Shortage Occupation List in April 2015. …
Responded
Arthur Cook
Concerns: Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.
Overdue
James Adams
Concerns: A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable consultant time.
Response (NHS England): • Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group (CCG) to develop a pathway for local implementation of guidance for thromboprohylaxis in ambulatory patients requiring temporary …
Response (James Adams): • The working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up. • Kernow CCG …
Responded
William Harnell
Concerns: Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.
Response (Plymouth Hospital NHS Trust): Plymouth Hospitals NHS Trust has reviewed processes so that all Emergency Department films and inpatient films between Sunday am and Friday 5pm are reported within 24 hours. They have also …
Response (Department of Health): The Department of Health acknowledges the concerns regarding delays in X-ray reporting and highlights actions being taken by Health Education England to increase the number of radiologists.
Response (william harnell): Cornwall Council is asking for guidance to be produced and disseminated to staff regarding timely placements for people who need such placements.
Responded
Leslie Murray
Concerns: Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Overdue
Matthew Crowley
Concerns: A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
Overdue
Freda Weston
Concerns: Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Response (Weston): Stockport NHS Foundation Trust will supply Patient Information Leaflets with monitored dosage systems, including a generic medicine patient information leaflet. All wards in the Medicine Business Group have access to …
Responded
Adam Rice
Concerns: There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Response (Adam Rice): West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff …
Overdue
Mandeep Singh
Concerns: Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
Response (North East Ambulance Service): NEAS has improved its paramedic resource base, with improved attrition rates, and is working to educate the public about appropriate use of services. They work with other agencies for road …
Responded
Marina Fagan
Concerns: A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in some hospitals.
Response (Department of Health): The Department of Health acknowledges the concerns about the availability of neurologists and waiting times, noting that it is the responsibility of providers to ensure appropriate staffing levels, and that …
Responded
Committee Recommendations (266) — showing 50 strongest matches
#32 —
Recommendation: We recommend again, that Health Education England publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years including an assessment of whether sufficient numbers are being trained. We further recommend that …
Gov response: The Committee recommended HEE publish independent annual reports on workforce shortages and future staffing requirements that cover the next five, ten and twenty years, and that these projections should also cover social care as well. …
Under Consideration
#31 —
Recommendation: It is clear that workforce planning has been led by the funding envelope available to health and social care rather than by demand and the capacity required to service that demand. Furthermore, there is no accurate, public projection of what …
Gov response: 5.9 The Committee recommended HEE publish independent annual reports on workforce shortages and future staffing requirements that cover the next five, ten and twenty years, and that these projections should also cover social care as …
Under Consideration
#16 —
Recommendation: We repeat our recommendation that HEE must be required (whether in its own right or as part of NHS England) to publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years, …
Gov response: Accept in principle. As set out in the response to recommendation 15, the Government recognises the importance of supporting frontline staff and the need for independently verified assessment of health, social care and public health …
Under Consideration
#21 —
Recommendation: Among comparable OECD countries the UK has relatively low numbers of hospital beds, nurses and doctors per 1,000 population and also carries out relatively low numbers of advanced diagnostic examinations.46 NHSE&I told us that it would take two to three …
Not Addressed
#10 —
Recommendation: Between 2010 and 2019 the NHS saw an average annual growth in emergency admissions of more than 3% and in urgent cancer referrals from GPs of more than 10%. Although there was relatively strong growth in the number of consultants …
Not Addressed
#3 —
Recommendation: The NHS will be less able to deal with backlogs if it does not address longstanding workforce issues and ensure the existing workforce, including in urgent and emergency care and general practice, is well supported. NHSE&I believes it will be …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2023 3.2 Ensuring that the NHS has a workforce in the right numbers and with the right skills to deliver service commitments to …
Accepted
#21 —
Recommendation: As part of the long-term plan for the cancer workforce, the Government and NHS England should develop specific proposals for improving the retention of experienced cancer staff, including targeting burnout and improving the day-to-day working conditions of staff. (Paragraph 115) …
Gov response: Building on the progress, the Government’s forthcoming 10 Year Cancer Plan will set a new vision for how we will lead the world in cancer care, including ensuring we have the right workforce in place. …
Accepted
#17 —
Recommendation: The Government and the NHS have recognised some of the issues with radiotherapy delivery in the NHS and have made welcome commitments to resolve these, such as investing in new radiotherapy machines and the proton beam centres in Manchester and …
Gov response: Until the 2021 Spending Review and subsequent publication of the NHS Capital Planning Guidance, the responsibility to replace equipment, including radiotherapy equipment, resided with NHS Trusts, using internally generated capital or other financing arrangements, i.e. …
Accepted
#17 —
Recommendation: The January 2019 NHS Long Term Plan originally committed to producing a workforce implementation plan by late 2019. In September 2020, the Department told us that it expected to publish the workforce plan following the December 2020 Spending Review.59 In …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: 2023 2.2 At the Autumn statement 2022, the government set out its commitment to publish a long-term workforce plan for the NHS in 2023 …
Not Addressed
#16 —
Recommendation: We have been raising concerns about the lack of long-term planning for the NHS workforce since well before the COVID-19 pandemic52. We have noted that among comparable OECD countries the UK has relatively low numbers of nurses and doctors per …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: 2023 2.2 At the Autumn statement 2022, the government set out its commitment to publish a long-term workforce plan for the NHS in 2023 …
Accepted
#3 —
Recommendation: The Department has started taking some action to address workforce challenges in social care, but vacancies have increased by 50% in the last year and the number of people working in social care fell in 2021/22 for the first time …
Gov response: The government disagrees with the Committee’s recommendation. According to Skills for Care, the vacancy rate in independent care providers was 10.7% in 2021-22, increasing from 7.0% the previous year. The rate had been around 7% …
Not Accepted
#2 —
Recommendation: We remain very concerned about the critical shortages across the NHS workforce and the Department’s repeated delays in publishing a strategy to address them. Workforce shortages are widespread across the NHS, and particularly acute in some specialisms, for example midwifery. …
Gov response: The government agrees with the Committee’s recommendation. long-term workforce plan for the NHS in 2023 and it will do so.
Accepted
#18 —
Recommendation: The Government need to publish an evidence-based plan, supported by up-to-date workforce modelling, setting out how it will increase the capacity and sustainability of all sectors of the specialist palliative and end of life care workforce, as part of the …
Response Pending
#17 —
Recommendation: Current shortages in the specialist workforce are putting palliative care services in an unsustainable position which threatens their ability to deliver equitable and high-quality palliative and end of life care. Extensive consultant vacancies, impending retirements, limited training places and widespread …
Response Pending
#27 — Government lacks a comprehensive long-term plan for the social care workforce
Recommendation: The Department informed us that the government has not set out an equivalent long-term plan for the social care workforce, because they are mainly private employees of independent companies.78 It told us, however, that there are steps it had been …
Not Addressed
#24 — NHS Long Term Workforce Plan addresses projected shortfall of up to 360,000 staff.
Recommendation: In the workforce plan, NHS England estimates that over a 15-year period, without action, there would be a shortfall of 260,000 to 360,000 staff by 2036–37. NHS England explained that, because it takes time to train people and that they …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2024 2.2 NHS England has revised the scope of the retention programme, in response to the cost of living impacts and the need …
Not Addressed
#18 — Adult social care workforce vacancies remain high and are worse in rural areas
Recommendation: We have repeatedly raised concerns about care workforce shortages. When we reported in 2018, vacancy rates for 2016–17 were 6.6%.38 The vacancy rate has increased since then and, as the NAO reported, in 2022–23 vacancies were 152,000, a rate of …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 In 2021, the department published its workforce strategy in Chapter 5 of People at the Heart of Care: adult social care reform and in …
Accepted
#4 — Set out plan to lead sector in addressing chronic adult social care workforce challenges.
Recommendation: Notwithstanding its recent efforts to make adult social care a more attractive career, the Department has still not produced a convincing plan to address the chronic staff shortages in the long-term. Workforce vacancies in adult social remain worryingly high with …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented In 2021, the department published its workforce strategy in Chapter 5 of People at the Heart of Care: adult social care reform and in 2023 published …
Accepted
#41 — Women's health hub model shows promise but faces systemic challenges and risks unequal access.
Recommendation: The expansion of the women’s health hub model has the potential to be a positive step towards providing the joined-up care and commissioning needed to effectively support women experiencing reproductive health conditions. However, the women’s health hub model exists within …
Gov response: We are committed to moving towards a neighbourhood health service, with more care delivered in local communities, to identify and address problems earlier and closer to home. Women’s health hubs are an example of this …
Not Addressed
#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
#11 — NHSE confident in future pandemic funding, but highlights workforce capacity as main concern.
Recommendation: Resilience to shocks is a key element of financial sustainability. We asked how well the NHS would cope financially in the event of another pandemic. NHSE expressed confidence that in the event of another pandemic government would provide any additional …
Not Addressed
#3 — Set out detailed plan for unprecedented NHS productivity gains, addressing staff retention.
Recommendation: NHSE displays a remarkable complacency about the realisation of future NHS productivity improvements, which, if achieved, would be unprecedented. According to official ONS measures, long-term productivity gains in the NHS averaged 0.6% a year over the period 1996–97 to 2018–19. …
Gov response: The government agrees with the Committee’s recommendation. pandemic. The most recent ONS publication of annual Public Sector Productivity shows: • NHS productivity continuing to recover in 2022-23, after the sharp rebound in productivity in 2021-22 …
Accepted
#29 — NHS dental workforce declines, facing over 5,500 unfilled vacancies nationally
Recommendation: The NAO reported that in 2023–24 there were 24,193 dentists providing some NHS dental care in England, a 2% decline on the total since 2019–20.87 NHSE data outlines that there is a large workforce gap that exists in NHS dentistry, …
Gov response: 1.5 Reforming the dental contract needs careful consideration and this will take time. In the meantime, the government is addressing the immediate challenges for patients trying to access NHS dental care by delivering 700,000 extra …
Partially Accepted
#6 — Publish dental graduate tie-in response and outline plans to attract and retain NHS dental professionals.
Recommendation: Without a workforce sufficiently supported to deliver NHS dental care, there will be no future for NHS dentistry and DHSC and NHSE have not yet done enough to address workforce issues. The total number of dentists delivering some NHS dental …
Gov response: The government agrees with the Committee’s recommendation. dentists is a key part of the government’s ambition to reform the dental contract. This work is underway but will take time. Whilst the new dental contract is …
Accepted
#1 — Northern Ireland's public services remain in crisis across health, education, and justice.
Recommendation: Northern Ireland’s public services remain in crisis. Its health service is under immense pressure, with long waiting lists, a struggling primary care sector and an acute mental health situation, in part due to Northern Ireland’s recent history. There are severe …
Gov response: We welcome your assessment on the state of public services, one year on from the previous Committee’s initial report, and recognise that improving public services will not be quick or easy. There are very real …
Not Addressed
#28 — Film and HETV industry too slow responding to critical skills shortages.
Recommendation: The film and HETV industry has been too slow to respond to skills shortages. That has had serious consequences for those working in it, and for the ability of domestic productions to afford to pay crews and creatives. Countless reviews, …
Gov response: The government agrees with the Committee that having data on industry investment in skills and training is vital in order to understand the landscape, and to develop a coherent skills strategy that reduces the risk …
Not Addressed
#30 — Significant workforce shortfall of medical microbiologists and virologists undermines NHS infection control.
Recommendation: Another challenge relates to the NHS workforce. There is a shortfall of professionals in this area, including of medical microbiologists and virologists.77 According to the Royal College of Pathologists, there is a 20% shortfall in consultant medical microbiologists and a …
Gov response: 5.1 The government agrees with the Committee’s recommendation Target implementation date: Summer 2026 5.2 The government is prioritising AMR and infection control across the healthcare system. This includes embedding AMR into national and regional strategies, …
Accepted
#5 — Ensure NHS England mainstreams AMR into everyday policy and addresses estate and workforce issues.
Recommendation: Addressing the threat of AMR should be a core part of all of the NHS’s work, including the fundamentals that reduce the spread of infection. Infection prevention and control measures, such as good hygiene practices, aseptic techniques and high standards …
Gov response: The government agrees with the Committee’s recommendation around the spread of infection through using its modular ward. The modular ward will generate evidence on how the hospital environment contributes to the spread of AMR infection …
Accepted
#47 — Develop comprehensive workforce strategy to improve recruitment, retention, and training across children's social care.
Recommendation: The Department for Education should develop a workforce strategy for children’s social care setting out how it will improve recruitment, retention and training across the children’s social care workforce, including social workers, residential care workers, personal advisers, educational psychologists, health …
Gov response: We recognise the critical importance of the children’s social care workforce and are committed to improving recruitment, retention and training across the sector. While pay and staffing remain the responsibility of local authorities and providers, …
Not Addressed
#46 — Serious recruitment and retention problems in children's social care workforce require wholesale review.
Recommendation: There is a serious problem with recruitment and retention in the social care workforce. High turnover and overstretched staff are exacerbating the instability experienced by children in care and increase the risk of 89 safeguarding concerns being overlooked. The Department …
Gov response: We recognise the critical importance of the children’s social care workforce and are committed to improving recruitment, retention and training across the sector. While pay and staffing remain the responsibility of local authorities and providers, …
Partially Accepted
#42 — Ensure all children's homes are led by registered managers; launch recruitment campaign.
Recommendation: The Department for Education must ensure that all children’s homes are led by a registered manager and set out the steps it intends to take to achieve this. Additionally, it should launch a recruitment campaign to raise the profile of …
Gov response: It is a legal requirement for all children’s homes to be led by a manager registered with Ofsted. We are committed to improving the registration process to help providers deploy managers more quickly, as set …
Not Addressed
#41 — High-quality residential care is essential, requiring improved workforce recruitment and training.
Recommendation: We agree that, for most children, a focus on supporting them to live in a family setting is the right one; however, this should not come at the expense of developing and maintaining high-quality residential care for children who need …
Gov response: It is a legal requirement for all children’s homes to be led by a manager registered with Ofsted. We are committed to improving the registration process to help providers deploy managers more quickly, as set …
Accepted
#27 — Severe shortage of foster carers exacerbated by inadequate support and undervalued work.
Recommendation: The shortage of foster carers is a key cause in the crisis in the supply of placements for children in care, with an additional 6,500 fostering families needed. Yet too many prospective foster carers do not complete the application and …
Gov response: We recognise the importance of supporting foster carers and addressing the challenges in recruitment and retention. The Government is investing significantly in foster care reforms through the Transformation Fund, including £25 million to support recruitment …
Accepted
#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
#21 — Case complexity, administrative landscape, and staff shortages contribute to London court delays.
Recommendation: MoJ and HMCTS told us that cases can take longer in London partly because there are more complicated cases, often with international dimensions. There is also a complicated administrative landscape with 33 different local authorities all doing things differently.44 HMCTS …
No Published Response
#66 — Shortages of educational psychologists and allied health professionals undermine quality of SEND support
Recommendation: Shortages of educational psychologists and allied health professionals, including speech and language therapists, occupational therapists, and physiotherapists are significantly undermining the availability and quality of SEND support. These workforce gaps delay assessments, restrict access to essential interventions, and place additional …
Gov response: The Department is working closely with DHSC and NHS England to improve access to community health services, such as speech and language therapy, for children and young people with SEND. As set out in the …
Accepted
#2 — Government intervention and public expenditure crucial to address clean energy sector skills gaps.
Recommendation: Fortunately, there is a lot of scope for smart policy and expenditure to be used to collaborate with the whole energy sector, as well as the education and skills sector, to empower and equip existing workers and new entrants to …
Gov response: The government partially agrees with this recommendation To ensure we have a robust talent pipeline for the clean energy workforce, we must ensure that every section of the population is aware of the career opportunities …
Accepted
#1 — Skilled labour supply insufficient to meet demand for clean energy and decarbonised buildings.
Recommendation: The supply of skilled labour does not currently match the levels of demand expected to be required if the UK is to fulfil Government’s ambitions to deliver clean energy by 2030 and decarbonised buildings by 2050. (Conclusion, Paragraph 29)
Gov response: The government agrees with this recommendation. The government is committed to tackling the barriers preventing the transition of existing energy sector workers. The majority of the workforce needed to meet our clean energy ambitions are …
Accepted
#6 — Removing Level 7 apprenticeship funding for over-22s jeopardises transport manufacturing's skilled worker supply.
Recommendation: We acknowledge that the Government is seeking to re-balance funding to prioritise people aged below 22. However, the removal of Government funding for level 7 apprenticeships for those aged 22 and older risks jeopardising the supply of experienced and highly …
Gov response: The Government has now brought forward its response to the consultation on public procurement. The response was published on 26th March 2026 following the consultation and subsequent stakeholder feedback between June-September 2025. With respect to …
Accepted
#21 — Ensure FCDO retains expertise and provides gender-specific funding to empower marginalised groups.
Recommendation: The FCDO must have the expertise and resources required to empower marginalised groups in decision-making forums, as well as the ability to equip them in their efforts to bring about lasting change in their communities. The FCDO will need to …
Gov response: Partially Agree 34. The FCDO is transitioning to differentiated development partnerships based on mutual benefit – taking account of country need and long term UK interest. The UK will prioritize our geographic ODA where humanitarian …
No Published Response
#15 — Pause FCDO restructuring until staffing, skills, equalities, and ODA impact assessments are completed.
Recommendation: We call on the Government to pause the processes currently underway until the following actions have been completed: a. a structured assessment of staffing required to deliver the Government’s priorities both in the UK and in countries with a diplomatic …
Gov response: Partially agree (Recommendation 3) Disagree (Recommendation 6) Disagree (Recommendation 7) 15. The FCDO is committed to ensuring that it has the development capability and technical expertise needed to deliver this government’s ambition on development, even …
No Published Response
#12 — Ensure missions have access to in-house thematic, geographic expertise, and vital local staff.
Recommendation: Missions must, therefore, have access to in-house expertise both on the ground and in the UK. This expertise needs to cover both thematic issues relating to poverty alleviation, as well as the geographic knowledge of specific contexts. Local staff are …
Gov response: Partially agree 22. The FCDO is taking a partnership-led approach to development. As part of this, our country network will have the flexibility to deliver the development our partners want and the FCDO is also …
No Published Response
#39 — Allocate increased funding, staffing, and expertise for SPS agreement and relevant food agencies.
Recommendation: The Government should find, allocate and disclose budgets and plans for increasing staffing, expertise, and funding to support its work on the SPS agreement and ensure timely delivery alongside other policy commitments. HM Treasury must increase the FSA’s flat budget …
Gov response: HMT and the FSA will keep budgets under review in the usual way. Any agreed adjustments would be confirmed at relevant Main or Supplementary Estimates.
No Published Response
#38 — Government resource capacity to deliver SPS agreement by 2027 deadline remains uncertain.
Recommendation: There is uncertainty regarding the Government’s resource capacity to deliver the extensive regulatory changes required to establish a common SPS area with the EU by the ambitious June 2027 deadline. This work is a substantial legislative and operational undertaking, which …
Gov response: HMT and the FSA will keep budgets under review in the usual way. Any agreed adjustments would be confirmed at relevant Main or Supplementary Estimates.
No Published Response
#18 — Social housing providers lack capacity to deliver improvements due to supply chain issues
Recommendation: The steps the Government is taking to rebuild the sector’s financial capacity to invest in new and existing homes will help providers to meet new regulatory standards. However, we are concerned that supply chain constraints, workforce shortages and the limited …
Gov response: 30. In April 2024, the Regulator of Social Housing introduced its new consumer regulation regime. The Regulator proactively seeks evidence and assurances that registered providers of social housing are delivering the outcomes set out in …
No Published Response
#16 — Local authority capacity for routine animal disease surveillance has significantly diminished over time.
Recommendation: The Department set out concerns it has about the capacity of local authority trading standards officers to undertake routine surveillance activities. While local authorities have stepped up to provide extra resources during recent outbreaks, capacity to undertake business-as-usual activities such …
Under Consideration
#14 — Disease outbreaks significantly compromise APHA's routine surveillance activities and performance targets.
Recommendation: Surveillance work, or ‘eyes and ears on the ground’, is vital to help detect new and re-emerging disease threats quickly and stop their spread. The Department’s and APHA’s approach to managing disease outbreaks is through a ‘surge capacity’ resourcing model, …
Gov response: 3.1 The government agrees with the Committee’s recommendation Target implementation date: May 2026 3.2 APHA’s surveillance activities are undertaken in accordance with the following definition - the systematic ongoing collection, collation, and analysis of information …
Accepted
#12 — Recruitment and retention of government vets significantly challenged by mental health, pay, and conditions.
Recommendation: APHA explained that difficulties in recruiting and retaining government vets are not unique to APHA or the UK. Key factors include: mental health issues relating to activities such as culling animals; pay and conditions; and working hours. APHA set out …
Gov response: 2.1 The government agrees with the Committee’s recommendation Target implementation date: March 2027 2.2 Current vet capacity challenges are being managed through initiatives such as pay allowances for vets. These allowances are used by certain …
Accepted
#11 — APHA veterinary staff vacancy rates remain high despite a slight recent decrease.
Recommendation: In 2023–24, APHA’s peak vacancy rate for vets was 24% (108 full-time equivalent staff) which had fallen to 20% (99 full-time equivalent staff) in April 2025.13 In correspondence received after the evidence session the Department stated that it has a …
Gov response: 2.1 The government agrees with the Committee’s recommendation Target implementation date: March 2027 2.2 Current vet capacity challenges are being managed through initiatives such as pay allowances for vets. These allowances are used by certain …
Accepted
#2 — Produce a veterinary workforce strategy to effectively address APHA's vet vacancies
Recommendation: Not enough is being done to tackle the high level of vet vacancies within APHA, which limits its ability to respond to an outbreak. APHA struggles to recruit and retain sufficient vets. APHA’s vet vacancy rate fluctuates– it was 20% …
Gov response: The government agrees with the Committee’s recommendation allowances for vets. These allowances are used by certain departments to support recruitment and retention within the Civil Service, including APHA. The Home Office underwent a regulatory reform …
Accepted
CQC Inspection Actions (53) — showing 50 strongest matches
We Can Recover CIC
The service did not have enough nursing and medical staff, who had completed basic training to keep people safe from avoidable harm. Although the provider had recruited nursing staff, most lacked previous experience in substance misuse. Arrangements to cover gaps …
Must Do
Verve Health
The service must ensure they have enough suitably competent, skilled and experienced clinical staff.
Must Do
Reside at Southwood
The provider must ensure that there are suitable numbers of staff on duty to meet people's needs.
Must Do
Oaklands Care Home
The provider did not have sufficient numbers of suitably skilled, experienced and qualified staff deployed at all times.
Must Do
Cranmore
The provider must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff.
Must Do
DMC Church View Practice
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
Must Do
Church Road
The registered person must ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the needs of service users.
Must Do
Charmes Care
The registered persons failed to ensure there was sufficient numbers of staff deployed to meet people's needs safely.
Must Do
Serenity House
The provider failed to ensure there were enough staff deployed to meet people's needs.
Must Do
Salus Care Group - Braunstone
The provider failed to ensure that they had sufficient staff employed and deployed to meet peoples care and treatment needs. Robust assessments to ensure people's needs were safely managed were not in place to protect people from the risk of …
Must Do
Nower House
The failure to ensure there were enough staff to meet people's needs was a breach of regulation 18.
Must Do
Leopold Muller Home
Systems were not in place to ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff were working at the home. This placed people at risk of harm and poor care. This was a breach of regulation 18 of …
Must Do
Leopold Muller Home
Systems were not in place to ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff were working at the home. This placed people at risk of harm and poor care. This was a breach of regulation 18 of …
Must Do
Bourne House
There was not sufficient numbers of suitable qualified, competent, skilled and experienced persons deployed to meet the needs of people living at the service. Staff were not consistently receiving appropriate support, training, professional development, supervision and appraisals as necessary to …
Must Do
Barton Park Nursing Home
There was not adequate nursing provision on day two of our inspection due to the registered manager being dismissed from post.
Must Do
B&H Care Ltd
The provider must ensure effective systems are in place to ensure there are enough staff available to keep people safe and meet people's care needs, preventing frequent late care calls and significant variations in care times.
Must Do
Ashbourne House - Torquay
The arrangements for staffing did not always ensure people's needs were met. There were not enough staff employed to meet people's needs.
Must Do
Aarondale House
The provider has failed to deploy sufficient numbers of staff. They had failed to ensure staff received induction, training and supervision to ensure they were competent in their role.
Must Do
Archers Point Residential Home
There were not enough housekeeping staff deployed.
Must Do
St Albans House
The provider should assess staffing levels.
Should Do
Spindrift Care Home Limited
Not all staff had received appropriate training to ensure they had the knowledge and skills to meet people's needs. Staff had not received a regular appraisal. The provider had not ensured a sufficient number of suitably qualified, skilled and experienced …
Must Do
Edwina Place
The provider should seek advice from a reputable source to review their system that ensured there was a right mix of skilled, trained, knowledgeable staff on duty to keep people safe.
Should Do
Charnwood
We recommend the provider consider reviewing the dependency levels of people and consider what this means for staffing levels in the afternoons and evenings.
Should Do
The Croft
Regulation 18 (Staffing)
Must Do
Nicholas House
The provider must ensure people are supported by a consistent staff team, and the staffing structure supports the delivery of person-centred care to people to support their independence and keep them safe from harm.
Must Do
Linda Lodge
The provider must ensure sufficient staffing.
Must Do
Clarendon Gardens
ensure a senior staff member or manager was on shift 7 hours each weekday to strengthen the leadership and oversight arrangements
Must Do
Ashdale Care Home
The provider had failed to ensure people received safe care by deploying sufficient staff to meet their needs.
Must Do
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with not having sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the service requirements.
Must Do
Ambleside - Luton
The provider must ensure that there are sufficient numbers of suitably qualified, skilled and experienced staff.
Must Do
Valewood House Nursing Home
There were insufficient numbers of suitably qualified, skilled and experienced staff to safeguard people’s health, safety and welfare.
Must Do
The Peter Gidney Neurodisability Centre
There was a lack of suitably qualified, experienced and skilled staff to meet people's needs.
Must Do
The Moat House
Sufficient numbers of staff were not always available to meet people's care and support needs.
Must Do
Pennine View
Regulation 18 HSCA RA Regulations 2019 Staffing
Must Do
Lincoln Lodge Residential Home for the Elderly
staffing levels should be reviewed.
Should Do
Home Comfort Care
The provider must ensure compliance with Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Holly House Residential Care Home
The provider must ensure there are sufficient staff to support people in a way that ensures their continued safety.
Must Do
We (Always) Care Under One Roof Limited
The provider must ensure sufficient staff are deployed.
Must Do
St Paul's Lodge
The registered person must ensure suitably qualified, skilled and experienced persons are deployed to meet people’s needs.
Must Do
St Clare's Hospice
The provider should investigate and carry out further analysis to understand the reasons for high staff sickness.
Should Do
Redcot Lodge Residential Care Home
The provider must ensure sufficient numbers of suitably competent and experienced staff are deployed.
Must Do
JDK Limited (Glenholme Care)
There were not enough staff employed to deliver the service which was needed to meet people’s needs
Must Do
Haversham House Limited
The provider must ensure systems are in place to ensure there are sufficient staff to maintain the cleanliness and maintenance of the home.
Must Do
Eleanor House
The provider must take action to ensure there were sufficient numbers of suitably qualified, skilled and experienced staff available at all times. This was to ensure people who used the service were provided with appropriate meaningful opportunities for social interaction …
Must Do
Benthorn Lodge
The provider must ensure that staffing levels are sufficient to meet people's care and support needs safely.
Must Do
Bellevue Healthcare Limited
The provider must ensure staff receive appropriate training in identifying and treating pressure ulcers, and that staffing levels and skills are adequate to provide safe care.
Must Do
Ashmore House
The provider must ensure sufficient numbers of suitably qualified, skilled and experienced staff are deployed.
Must Do
Ashcroft House - Leeds
The provider must comply with Regulation 18 HSCA RA Regulations 2014 Staffing.
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure safe care and treatment, including accurate care records, safe medicine management, appropriate risk assessments, proper recording and investigation of accidents and incidents, and sufficient staffing to prevent missed or late calls.
Must Do
Care Outlook (Bellerophon House)
Some people reported delays to their care which meant they were left waiting for support. One person told us this meant having to wait to be transferred into their chair as they needed to be hoisted to be moved.
Should Do
PPO Death in Custody Recommendations (9)
The Head of Healthcare and Greater Manchester Mental Health Services
The Head of Healthcare and Greater Manchester Mental Health Services should consider what additional support can be put in place to address staffing shortages at Garth and consider how they can reasonably deliver a meaningful healthcare resource.
The Head of Healthcare (HMP Nottingham)
The Head of Healthcare should ensure there is adequate staffing within the mental health team to allow the team to provide the service for which it is commissioned.
The Director General of Prisons and MoJ People Group
The Director General of Prisons and MoJ People Group should consider what additional support can be put in place to address staffing shortages at Humber and consider how it can reasonably deliver a meaningful regime and deliver key work in …
The Head of Healthcare
The Head of Healthcare should develop a workforce strategy to address chronic understaffing as a matter of urgency.
The Director General of Prisons
The Director General of Prisons should urgently consider what additional support can be put in place to address staffing shortages at The Mount and how the prison can reasonably be expected to deliver an effective drug strategy and regime.
Manx Care
Manx Care should ensure there is a dedicated lead pharmacy provision at Isle of Man Prison and there is a prescriber available every day, even if that is for remote prescribing.
The Department of Health and Social Care and Manx Care
The Department of Health and Social Care and Manx Care should review the current provision of mental health services at Isle of Man Prison and provide a dedicated mental health service, which is sufficiently resourced to meet the needs of …
The Director General of Prisons
The Director General of Prisons should urgently consider what additional support can be put in place to address staffing shortages at The Mount and consider, as a matter of urgency, how it can reasonably be expected to deliver an effective …
The healthcare provider
The healthcare provider should ensure there is a GP onsite in line with the primary care service specification for prisons in England.
NAO Audit Recommendations (6)
The adult social care market in England
b) develop a workforce strategy, in line with its previous commitments, to recruit, retain and develop staff, aligned with the NHS People plan where appropriate;
Accepted
Progress in improving mental health services in England
b) Either separately or as a distinct part of the overall NHS workforce plan due in 2023, DHSC and NHSE should publish a longer-term mental health workforce recruitment and retention strategy and a costed plan, that reflects the volume and …
Accepted
The rollout of the COVID-19 vaccination programme in England
In the light of the expanded and accelerated booster programme, NHSE&I should take additional steps to manage the vaccine workforce and its welfare sustainably, and to examine how the programme can minimise its potential adverse impact on other health and …
Accepted
Resilience to animal disease
e work with stakeholders in the veterinary sector to develop a workforce strategy that addresses the challenges currently facing the veterinary workforce, particularly in government but also considering the private sector;
Accepted
Child Maintenance Client Funds Accounts 2020-21: 1993 and 2003 Schemes Account
• allocates sufficient resource to provide appropriate customer service and timely responses to queries and complaints on cases; and
Partially accepted
Child Maintenance Client Funds Account 2019-20
• allocates sufficient resource to provide appropriate customer service and timely responses to queries and complaints.
Partially accepted
IMB Annual Reports (99) — showing 50 strongest matches
Eastwood Park (2022)
HMP/YOI Eastwood Park faced a challenging reporting year (Nov 2021 – Oct 2022), marked by critical staffing shortages (17.5% below target), two deaths in custody, and exceptionally high self-harm levels, leading the IMB to no longer consider it safe for all women. The prison struggled with an increasing number of women with complex mental health needs, exacerbated by inadequate facilities and a lack of external secure placements, resulting in extended periods of segregation for some. Despite these issues, the Board commended staff professionalism, welcomed the new ONE women’s centre, and noted the prison’s high functional skills achievements.
PRISON
Key concerns
Foston Hall (2022)
HMP/YOI Foston Hall faced significant challenges in the reporting year, primarily due to acute staff shortages which severely impacted the regime, leading to frequent curtailments and long periods of cell confinement. Key concerns included high levels of self-harm and violence, inadequate accommodation, and slow progress in healthcare provision and resettlement outcomes. Despite these difficulties, the Board commended staff dedication and noted some improvements, such as the opening of better quality accommodation and enhanced chaplaincy services.
PRISON
Key concerns
Norwich (2023)
The IMB report for HMP/YOI Norwich highlights persistent staff shortages as the overarching issue, leading to a restricted regime with prisoners locked up for extended periods daily. Key concerns include high levels of self-harm and violence, an overstretched mental health team, and a lack of purposeful activity and rehabilitation programs for long-term and IPP prisoners. The Board also notes the inhumane detention of foreign national prisoners beyond their sentences and prisoners with severe mental health issues in unsuitable facilities.
PRISON
Key concerns
Low Newton (2023)
HMP/YOI Low Newton is a well-managed women's prison that successfully adapted its regime post-Covid. While praised for its safe environment, estate improvements, and dedicated staff, it is significantly hampered by staff shortages, impacting regime delivery and key worker scheme consistency. The Board highlights concerns regarding funding for essential facilities, the management of complex prisoners, and the need for improved transport arrangements and oversight of disciplinary processes.
PRISON
Key concerns
Cookham Wood (2021)
HMYOI Cookham Wood operated with a restricted regime during the reporting year due to Covid-19, leading to boys being locked in their rooms for extended periods and a significant reduction in purposeful activity and education. Staff shortages exacerbated these issues, though staff dedication and the transformation of the resettlement team were noted positives. Key concerns include the continued lack of secure mental health beds, delays in transferring 18+ year-olds, and inadequate IT facilities, all contributing to an environment the IMB deemed detrimental to the boys' wellbeing and development.
PRISON
Key concerns
Downview (2022)
HMP/YOI Downview experienced another year significantly impacted by the Covid-19 pandemic, leading to a restricted regime and challenges across various departments. While the Board found the prison safe and prisoners treated fairly, it raised significant concerns regarding the management and provision of healthcare, staffing pressures, and the lack of digital access for education. These issues highlight the ongoing difficulties in maintaining optimal conditions and services for prisoners under pandemic and resource constraints.
PRISON
Key concerns
Belmarsh (2022)
HMP Belmarsh experienced a challenging reporting year with improvements in health and wellbeing provision and a commitment to safety, though HMIP noted safety had deteriorated. The prison addressed equality and diversity issues through dedicated leadership and improved data, but concerns remain regarding disparities in outcomes for protected characteristics. Staffing issues, particularly high ‘non-effectives’ despite target numbers, curtailed regimes and impacted key worker compliance, while lost property and prolonged mental health transfer waits persisted as significant and repeated concerns.
PRISON
Key concerns
Chelmsford (2022)
HMP Chelmsford, a category B local prison, showed mixed performance in the reporting year ending August 2022. While levels of violence and self-harm decreased, and there were no deaths in custody, significant concerns persist regarding overcrowding (49% of prisoners sharing single cells) and long-standing issues with lost prisoner property. Staff shortages heavily impacted healthcare appointments, purposeful activity, and key worker effectiveness, contributing to many prisoners spending extended periods locked in cells.
PRISON
Key concerns
Isis (2022)
HMP/YOI Isis, a training prison for young adults and Category C men, housed around 600 prisoners in 2022. The Board noted an encouraging drop in self-harm and decreasing trends in violence and use of force, alongside effective healthcare leadership. However, significant concerns remain regarding persistent staffing shortages, insufficient time out of cell, and poor provision of purposeful activity and accredited rehabilitation programs, which hinder prisoners' progression and resettlement.
PRISON
Key concerns
Frankland (2022)
HMP Frankland, a high-security training prison, has operated near its 852 capacity. The Board noted positive developments including staff efforts to maintain safety, the continuation of social video calls, and strong educational engagement. Key concerns include chronic healthcare staffing shortages, persistent issues with property tracking, the ingress of illicit drugs, and the impact of heating problems on workshop availability.
PRISON
Key concerns
Hindley (2022)
HMP/YOI Hindley was deemed a safe environment with reduced violent incidents, but persistent staffing shortages led to extended lockdowns, negatively impacting prisoner wellbeing and mental health. The Board noted an increase in use of force and concerns over delays in parole hearings and inquests. While healthcare was satisfactory, low purposeful activity engagement and a lack of a clear incentives scheme remain significant issues.
PRISON
Key concerns
Lowdham Grange (2023)
HMP Lowdham Grange experienced a challenging reporting year (Feb 2022 – Jan 2023) marked by significant contract transition and refurbishment works. This led to a deterioration in safety, increased self-harm and assaults, and a decline in staff morale and prisoner engagement. Despite some positive healthcare developments like a new wellbeing centre, services remained below community standards, compounded by staffing shortages.
PRISON
Key concerns
Full Sutton (2022)
This report for HMP Full Sutton (Jan-Dec 2022) highlights persistent staff shortages, which led to regime lockdowns and reduced time out of cell. Despite these challenges, the prison maintained a safe and humane environment, showing improvements in education and complaint handling. Key concerns include drug testing levels, inconsistent equalities meetings, and the ongoing development of the STEP unit, with a shortfall in psychological and nursing staff also noted.
PRISON
Key concerns
Garth (2022)
HMP Garth, a Category B training prison, grapples with severe staff recruitment and retention issues, resulting in a largely inexperienced workforce and an ineffective key worker scheme. The restrictive regime, a consequence of staffing problems and post-pandemic recovery, limits prisoners' time out of cell and access to purposeful activity. Key concerns include the deteriorating estate, inadequate provisions for disabled individuals, and the persistent challenges faced by IPP prisoners, alongside ongoing issues with property transfers and an understaffed Offender Management Unit.
PRISON
Key concerns
Lewes (2023)
HMP Lewes continues to face severe challenges, primarily driven by staff shortages that restrict the regime, leaving many prisoners out of cell for only an hour a day. This has contributed to significant increases in self-harm and assaults on staff, while issues with healthcare provision, mental health support, and the decency of accommodation persist. The Board highlights the disproportionate use of force against BAME prisoners and the ongoing lack of resettlement support for those on remand.
PRISON
Key concerns
The Mount (2023)
HMP The Mount faced a challenging year ending February 2023, marked by a severe drug crisis involving Fentanyl-laced Spice, resulting in nine deaths, five of which were drug-related. Persistent staffing shortages led to a restrictive regime, limiting prisoners' access to education, work, and purposeful activity. Key concerns included overcrowding from cell doubling, significant healthcare waiting times exacerbated by escort shortages, and a failure to deliver adequate resettlement and offending behaviour programmes, contributing to an increase in prisoner complaints.
PRISON
Key concerns
Onley (2023)
HMP Onley, a Category C training and resettlement prison, faced significant challenges primarily due to persistent officer staff shortages during the reporting year. These shortages severely impacted the daily regime, key work delivery, access to education and workshops, and overall purposeful activity, leading to prisoners spending prolonged periods in their cells. The Board also raised concerns about illicit substances, food quality, and delays in prisoner property, while commending positive staff-prisoner relationships and efforts in resettlement and employment on release.
PRISON
Key concerns
Rochester (2023)
HMP/YOI Rochester maintained a stable and safe environment despite ongoing staff shortages, which impacted the regime for much of the year. While staffing improved by year-end, concerns persist regarding dilapidated buildings, property losses, and the availability of illicit drugs. The Board noted good mental healthcare provision and staff-prisoner relationships but raised significant concerns about the lack of suitable accommodation for released prisoners and the low education attendance rates.
PRISON
Key concerns
Send (2023)
HMP Send is a closed women's prison that made significant efforts to ensure prisoner safety and humane treatment during a challenging year. While the Board noted positive staff-prisoner relationships, persistent staff shortages, particularly in OMU and probation, negatively impacted services and progression. Key concerns include high self-harm rates, the lack of digital in-cell technology, the unjust detention of IPP prisoners, and property issues during transfers.
PRISON
Key concerns
Swaleside (2023)
HMP Swaleside experienced an unprecedented year of staff shortages, severely impacting the regime and humane treatment of prisoners with restricted time out of cell. Despite these challenges, the Board commends the SLT and staff for implementing an improving regime, which saw a decline in violence and self-harm incidents. Key concerns remain around staff retention, the poor state of facilities, long segregation times, inadequate resettlement support, and the high number of deaths in custody.
PRISON
Key concerns
Lancaster Farms (2023)
HMP Lancaster Farms, a category C resettlement prison, has largely provided a safe environment, though some pandemic regime restrictions were slow to lift. While primary healthcare is reasonable, mental health provision faces significant challenges due to staffing and a lack of specialist transfer capacity. Key worker contact and prisoner property management remain ongoing concerns for the Board, alongside issues of cell decency and delayed purposeful activity opportunities.
PRISON
Key concerns
Styal (2023)
HMP/YOI Styal faced significant challenges during the reporting year, primarily due to staffing shortages that compromised safety, regime consistency, and access to essential services. The prison recorded high rates of assaults and self-harm, often linked to an unpredictable daily routine. Despite these issues, the Board noted positive staff-prisoner relationships, improvements in induction and MBU facilities, and Styal's leading performance in employment outcomes for women on release.
PRISON
Key concerns
Pentonville (2023)
HMP Pentonville, a Category B local prison, faced significant challenges in 2022-2023, primarily due to overcrowding, antiquated facilities, and staff shortages impacting the regime and key work scheme. While the prison achieved notable successes in disrupting contraband and establishing a Neurodiversity Unit with positive outcomes, concerns persist regarding vulnerable prisoner safety, low time out of cell, and minimal resettlement support for its large remand population. Healthcare services showed improvements in patient access and staffing, but overall infrastructure and staffing levels continue to hinder humane conditions and effective rehabilitation.
PRISON
Key concerns
Isle of Wight (2022)
HMP Isle of Wight experienced a challenging 2022, marked by a population increase and the gradual easing of Covid restrictions, which allowed for a return to some normal regime activities. However, chronic staff shortages significantly hampered access to work, education, and healthcare, leading to prisoners spending considerable time locked up. The Board raised serious concerns regarding the inadequacy of mental health provision, the impact of staff shortages on all aspects of prison life, and the need for clarity and funding for the estate and the management of the Category C prisoner population.
PRISON
Key concerns
Stafford (2023)
HMP Stafford, a Category C training prison, generally provides safe and humane treatment, with significant improvements in medicines management. However, the report highlights critical issues, including the long-standing and hazardous state of prison roadways, which poses a serious safety risk. Persistent staff shortages continue to disrupt the regime, leading to lost activities, and a self-inflicted death involving an IPP prisoner raised serious questions. Additionally, concerns were noted regarding security compliance, reduced library services, and service delivery from the new visits management contractor.
PRISON
Key concerns
Stoke Heath (2023)
HMP/YOI Stoke Heath, a Category C training and resettlement prison, experienced an increase in self-harm incidents and near misses, alongside a noticeable rise in illicit items. While overall violence remained low, prisoners spent more time in their cells due to staffing shortages and inadequate purposeful activity, impacting sentence progression. Healthcare provision was generally met, though dental waiting times were long and planned mental health interventions limited. The Board highlighted concerns regarding prisoner property, resettlement support, and the need for more varied education and work opportunities.
PRISON
Key concerns
Nottingham (2023)
HMP/YOI Nottingham experienced a reduction in self-harm and use of force, but assaults on both prisoners and staff increased. Key challenges included inadequate provision for prisoners with severe mental health issues and disabilities, significant healthcare staff shortages, and concerns over the complaints system and property loss. The report also highlighted regime curtailments due to staff training and uncertainty for IPP prisoners.
PRISON
Key concerns
Portland (2023)
HMP/YOI Portland demonstrated a well-controlled environment with positive staff-prisoner relations and good physical facilities during the reporting year ending March 2023. However, the Board highlighted significant challenges in mental health provision due to staffing shortages, a fragmented resettlement program, and persistent issues with property delays. Recommendations focused on better funding for resettlement, improved communication regarding property, and prioritising key work to support prisoner wellbeing and progression.
PRISON
Key concerns
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
Feltham (2023)
Feltham, comprising a YOI (A side) and a Cat C prison (B side), faced significant challenges in the reporting year ending August 2023, primarily due to severe staff shortages impacting regime delivery, time out of cell, and purposeful activity. While staff were commended for their dedication, these shortages led to increased incidents on A side and curtailed essential services and rehabilitative programs across both sides. Key concerns also included the inadequate education provision for separated young people, safety in communal showers on B side, and the ongoing issue of lost prisoner property.
PRISON
Key concerns
Wormwood Scrubs (2023)
HMP Wormwood Scrubs faced significant challenges during the reporting year, including overcrowding and acute staffing shortages, which adversely impacted safety, regime delivery, and healthcare provision. Many prisoners spent extended periods locked in their cells with limited purposeful activity. Concerns persist regarding mental health transfer delays, an antiquated estate unsuitable for disabled prisoners, and poor food quality, though positive efforts in induction, reading support, and some service improvements were noted.
PRISON
Key concerns
Parc (2023)
HMP/YOI Parc reported eleven deaths in custody and a substantial increase in illicit item finds during the reporting period. The Board noted significant issues with inadequate mental health provision, excessive waiting lists for appointments, and critical staffing shortages impacting key worker sessions, healthcare, and education. Concerns were also raised about the quality and quantity of food, ineffective complaints handling, and the anxiety experienced by IPP prisoners due to release uncertainty. Positively, self-harm and violence incidents saw significant reductions.
PRISON
Key concerns
Bronzefield (2024)
Bronzefield faced significant challenges in the reporting year, primarily due to severe staff shortages impacting all aspects of the regime, leading to prisoners being locked up for extended periods and missing activities. Healthcare delivery was suboptimal due to lack of staff and poor coordination, resulting in medication delays and cancelled appointments. The prison also grappled with a high incidence of self-harm and challenges in managing complex, mentally unwell prisoners, compounded by external bed shortages.
PRISON
Key concerns
Feltham (2024)
HMP/YOI Feltham faces significant challenges, particularly high staff absence severely impacting regime delivery and time out of cell for both young people and adults. The physical environment is in a poor state, with persistent issues like leaking roofs and mould, alongside a worrying increase in violence, including staff assaults on Feltham B, and a rise in contraband finds. While healthcare provision is generally good and staff are commended for their dedication, the lack of purposeful activity, effective key worker sessions, and the closure of the Enhanced Support Unit hinder rehabilitation and overall prisoner wellbeing.
PRISON
Key concerns
Brinsford (2024)
HMP Brinsford, a resettlement prison for young men (18-22 with temporary extension to 29), operates at full capacity of 577, with an average population of 529. The report highlights improvements in self-harm reduction and healthcare provision, but raises significant concerns about low staffing levels impacting safety, the ongoing increase in violence, and the critical lack of purposeful activity places. There are also persistent issues with infrastructure, property management, and delays in transferring prisoners with severe mental health needs.
PRISON
Key concerns
Liverpool (2024)
HMP Liverpool, a Category B reception prison, continued to improve in some areas under new leadership despite persistent staffing challenges. Concerns escalated regarding prisoner safety, including increased self-harm, violence, and use of force, alongside significant delays in mental health transfers and regime delivery. The prison also struggles with the entry of illicit items and maintenance issues with its Victorian infrastructure.
PRISON
Key concerns
Isle of Wight (2024)
HMP Isle of Wight saw a less safe environment in 2024, with significant increases in assaults, self-harm, and use of force, largely attributed to rising drug availability and staffing pressures, especially among probation and mental health teams. Key concerns include a lack of secure hospital beds for mentally ill prisoners, long healthcare waiting times, and issues with the regime, including poor laundry facilities and food service. The Board highlights improvements in education attendance, neurodiversity support, and some aspects of reception and induction, while also noting repeated recommendations regarding mental health transfers and probation staffing remain unaddressed.
PRISON
Key concerns
Swinfen Hall (2025)
HMP Swinfen Hall continued to struggle, delivering reduced outcomes for young adults despite considerable efforts by the leadership. The prison is under-resourced, leading to safety concerns, staff confidence issues, and frequent weekend wing closures. Key areas like purposeful activity, staff-young adult relationships, and the paper-based application system remain inadequate. While some security improvements were noted, the overall regime and support for complex needs, including neurodiversity, require significant development.
PRISON
Key concerns
Winchester (2025)
HMP/YOI Winchester continues to face significant challenges including persistent overcrowding, staffing pressures, dilapidated infrastructure, and high levels of self-harm and violence. Despite these issues, the Board notes staff professionalism and adaptive responses, particularly in addressing the HMIP Urgent Notification. The prison is making positive efforts towards improvement, with some progress in repairs and adapting the regime, though key concerns like illicit substance ingress and healthcare provision persist.
PRISON
Key concerns
Fosse Way (2025)
HMP Fosse Way faced significant operational challenges in its second year, including high prisoner churn, staffing shortfalls, and persistent building deficiencies like unsuitable furniture and failing lifts. Healthcare provision was unstable, with cancelled appointments and no overnight service, compounded by delays in mental health transfers. While purposeful activity and vocational training were praised, many places remained unallocated, and drug finds were a continued concern.
PRISON
Key concerns
Bedford (2025)
HMP/YOI Bedford, a Category B reception and resettlement prison, continues to face challenges with overcrowding, high levels of violence, and pervasive illicit item use. While some improvements have been made in reception and living conditions, the healthcare service is under significant strain, evidenced by a CQC warning notice. The Board also highlights concerns regarding staff retention (due to visa issues), a limited education curriculum, and an antiquated paper-based system for property and complaints.
PRISON
Key concerns
Bronzefield (2025)
HMP/YOI Bronzefield, a women's local and YOI prison, reported a population of 506 and a CNA of 5271. While some progress was noted in leadership and property management, the report highlights significant concerns regarding healthcare delivery, staffing pressures, and the impact of roll-counts on the regime. Mental health services remain strained, and issues with food provision, complaint handling, and resettlement support persist, many of which were repeated from previous years.
PRISON
Key concerns
Featherstone (2024)
HMP Featherstone faced challenges including the dilapidated state of its facilities, persistent issues with property management, and stretched healthcare services, particularly for mental health. However, the Board observed improvements in staffing levels, education provision, and reduced waiting times for doctors and dentists. Key concerns remain around the prison's aging infrastructure, the treatment of mentally unwell prisoners in segregation, and inconsistent staff culture.
PRISON
Key concerns
Cardiff (2025)
HMP Cardiff saw a significant reduction in self-harm, use of force, and violence incidents this year, alongside positive developments like the Launchpad project and improved GP services. However, the Board remains concerned about persistent issues such as severe staffing shortages in healthcare, particularly nursing and pharmacy, and delays in mental health transfers. Prison conditions, including heating, water, and accessibility, continue to be problematic, and the key worker scheme needs greater prioritisation amidst ongoing population pressures.
PRISON
Key concerns
Onley (2020)
HMP Onley experienced a challenging year with a restricted regime, largely due to staffing shortages, though improvements were seen towards the end. Key concerns include significant issues with property transfers, a dysfunctional complaints process, and a lack of purposeful activity leading to prisoners spending extended periods in their cells. The Board highlights persistent problems with resettlement progression, including missing OASys reports and slow transfers, alongside concerns about drug availability, self-harm incidents, and the general state of the estate. While staff-prisoner relationships improved and the OMiC model showed promise, the report calls for urgent action on staffing, regime provision, and inmate progression.
PRISON
Key concerns
Cardiff (2020)
HMP Cardiff maintained a reasonably safe environment with low violence, but self-harm incidents increased to 712, with four deaths in custody (three self-inflicted). The COVID-19 pandemic severely restricted the regime, impacting purposeful activity, time out of cell (1.5 hours daily), and overall prisoner wellbeing. Persistent staffing shortages hampered healthcare and mental health services, while disparities for BAME prisoners in areas like segregation and dangerous prisoner labels remained a concern.
PRISON
Key concerns
Erlestoke (2021)
HMP Erlestoke generally maintained a safe and humane environment during the reporting year ending March 2021, despite the challenges of Covid-19. Key improvements included a significant reduction in violence, commendable healthcare management of a Covid-19 outbreak, and improved resettlement planning. However, concerns remain regarding a troubling increase in self-harm, inadequate provision for prisoners with complex needs and IPP sentences, estates issues, and the impact of regime restrictions on purposeful activity.
PRISON
Key concerns
Bullingdon (2021)
HMP Bullingdon faced significant challenges during the reporting year (July 2020 – June 2021), exacerbated by Covid-19 restrictions which led to extensive in-cell time and impacted various services. The Board noted chronic overcrowding, an increase in self-harm incidents, and persistent issues with staff experience levels and the provision of mental healthcare. Progression and resettlement efforts were hindered by a high turnover of prisoners, predominantly those on remand or serving short sentences, while the effectiveness of drug interception measures remains a concern.
PRISON
Key concerns
Elmley (2021)
HMP Elmley experienced a challenging year ending October 2021 due to its status as a COVID-19 outbreak site, leading to highly restricted regimes and persistent staffing shortages. The Board noted positive initiatives like the Accelerator project and OMU surgeries, but raised significant concerns regarding prolonged confinement, inadequate food budget, and issues with property loss and unlock list management. The report highlights critical needs for improved staff recruitment and retention, better analysis of self-harm incidents, and a review of external service contracts.
PRISON
Key concerns
Hull (2022)
This report for HMP Hull, ending February 2022, highlights a challenging period marked by the ongoing impact of Covid-19 restrictions, which limited IMB monitoring capacity and led to significant staff absences. While safety metrics showed reductions in violence, self-harm, and use of force, serious concerns remain regarding healthcare provision, which was deemed failing by HMIP and led to contract termination. Other critical issues include insufficient cell capacity, restricted key worker support, and ineffective resettlement pathways due to poor external agency communication.
PRISON
Key concerns
IMB Recommendations (61) — showing 50 strongest matches
Foston Hall (2021)
The IMB is concerned about: staffing pressures in healthcare and mental health, impacting on services provided.
Governor / Director
Cardiff (2021)
The second has been raised by the temporary clinical director who has identified the need for increased GP hours to cover the health needs of the men.
NHS / Healthcare Provider
Cardiff (2021)
The Board has two concerns in relation to healthcare which we would ask the Health Minister to consider with Cardiff and the Vale Health Board. Both relate to staffing: the first is the ongoing issue with lack of cover for pharmacists, which can lead to locum pharmacists being brought in on an emergency basis and affects the planning of the …
NHS / Healthcare Provider
Lowdham Grange (2022)
To exert pressure on the commissioners of Nottinghamshire Healthcare NHS Trust to secure and maintain staffing at a level to provide the service required for all prisoners’ health and wellbeing needs.
Governor / Director
Frankland (2022)
What plans does the Ministry of Justice (MOJ) have to address the chronic staffing shortages in healthcare?
Ministry of Justice
Bronzefield (2024)
How does NHS England plan to address the shortage of GPs, nurses, and substance misuse practitioners in Bronzefield? (6.1, 6.5)
NHS / Healthcare Provider
Heathrow Immigration Removal Centre (2021)
The healthcare manager’s efforts to achieve full staffing should continue to be supported, especially in the area of mental health, which is seriously understaffed.
NHS / Healthcare Provider
Downview (2021)
Provide support to enable prompt recruitment to critical psychology intervention roles to address reduced capacity, headcount, and waiting lists, particularly during a time of increased demand.
HMPPS
Isle of Wight (2022)
recognising the staffing challenges, the Mental Health Department needs to be brought up to establishment strength.
Governor / Director
Heathrow Immigration Removal Centre (2022)
The Healthcare Manager’s efforts to achieve full staffing should continue to be supported, especially in the area of mental health, which is seriously understaffed.
NHS / Healthcare Provider
Foston Hall (2022)
The lack of available clinical staff at night-time on occasion (see paragraph 6.2.3)
Governor / Director
Usk and Prescoed (2024)
When will the Minister review the healthcare staffing establishment so that it reflects the changing case mix and planned expansion?
Ministry of Justice
Oakwood (2024)
The Board is concerned that there are ongoing recruitment and retention issues for staff working in prison mental health services when the demand is increasing. There is still a vacancy for a psychologist at HMP Oakwood and a number of roles are being covered by agency or bank staff. What does the Minister plan to do to improve this situation?
Ministry of Justice
Nottingham (2024)
To address with the health care provider the continuing shortcomings in the service provided, in particular the staff shortages and the lack of a deputy.
Governor / Director
Deerbolt (2024)
The Board urges HMPPS to visit Deerbolt, meet the healthcare team, urgently review the staffing model and support additional resources clearly needed to meet the demands from the establishment.
HMPPS
Portland (2020)
The provision of healthcare services has suffered for lack of a psychologist and psychiatrist at times during the reporting period. The appointment and retention of psychologists and psychiatrists to posts in Portland have been problematic since the contract transferred from the local health authority. It would be helpful if the reasons for this could be explored and, where possible, addressed.
Governor / Director
Lindholme (2020)
Will the Prison Service consider what measures are needed to ensure that the staffing levels of the healthcare provider are maintained as per contract (see section 8)?
HMPPS
Leeds (2020)
Is the Governor able to support the healthcare team in their request to the NHS for another nurse to work as part of the reception team?
Governor / Director
Dover (2020)
The medical provision in the holding rooms should be expanded to ensure permanent access to more than one medical professional at busier times. The expansion to 24 hours per day was achieved just after the end of the reporting period; however more than one medic should be available.
Other
Gartree (2021)
The Board acknowledges the Minister’s response to the question raised in our last annual report regarding the national partnership agreement for prison healthcare. The Board requests the Minister provide a further update on resources being planned post-Covid-19 to enable the delivery of measures outlined in the partnership agreement specifically for Gartree, as the Board has increasing concerns regarding the mental …
Ministry of Justice
Usk and Prescoed (2022)
a replacement appointment is urgently needed.
NHS / Healthcare Provider
Send (2022)
Recruitment issues continue to impact on all areas of prison life including operational staff, healthcare and catering (3.1, 5.1, 6.1, 6.2).
HMPPS
Isle of Wight (2022)
Efforts should also be made to prioritise staffing to escort prisoners for health care appointments.
Governor / Director
Hewell (2022)
Healthcare contracts should be reviewed to ensure that there is safe out-of-hours cover; this will improve the health, safety and wellbeing of prisoners, reduce the number of staff hours needed to escort men to outside provision, and reduce the pressure on already overstretched ambulance and NHS resources.
NHS / Healthcare Provider
Ashfield (2022)
Can the Minister raise with the Secretary of State for Health and Social Care the Board’s concerns that healthcare resource shortages (both physical and mental health) in a prison environment are putting the wellbeing of prisoners at risk?
NHS / Healthcare Provider
Oakwood (2023)
The Board is concerned that there has been a vacancy for a Psychologist for the duration of the reporting period. A campaign to recruit a Psychologist is ongoing but reports indicate that recruitment is difficult, with too few Psychologists who are either available or willing to work within a prison environment. The career pathway, training and recruitment of Psychologists should …
Other
Wandsworth (2024)
With the current staff shortages, will it be possible to operate the new healthcare centre safely?
Governor / Director
Featherstone (2024)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
Bronzefield (2024)
NHS England specifies the provision of face-to-face GP services, seven days a week. However, to date, this has not been achieved. How and when does NHS England intend to remedy this lack of provision? (6.1)
NHS / Healthcare Provider
The Verne (2025)
Will HMPPS consider funding 24-hour on-site clinical cover at the Verne, provided by a nurse or paramedic? (See 6.5.2)
HMPPS
Dovegate (2025)
The demand for specialised provision for prisoners with mental health and/or personality disorders needs remains higher than the provision available. Will the Prison Service create a structured plan to increase both spaces and staff to support them, with clinical staff as well as administrative?
HMPPS
Bronzefield (2025)
How does NHS England plan to address the shortage of experienced nurses in Bronzefield (6.1, 6.5)?
NHS / Healthcare Provider
Yarl’s Wood (2020)
The Board recommends that NHS England maintains the excellent staffing levels and services of the last year.
NHS / Healthcare Provider
Long Lartin (2020)
Recruitment of healthcare staff continues to be hampered by the extremely slow vetting process.
HMPPS
Foston Hall (2021)
The IMB is concerned about: the ongoing absence of initial screening of prisoners for learning difficulties and disability (LDD) due to a staffing shortage.
Governor / Director
Foston Hall (2021)
The IMB is concerned about: the ‘short-term’ closure of the mental health office to facilitate the demolition of A and B wings, which by November had extended into three months, causing acute problems for the delivery of mental health services
Governor / Director
Yarl’s Wood (2022)
The Board recommends that NHFT continues to maintain the excellent staffing levels and services of the last year.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available on, a 24/7 basis, to provide detained individuals with necessary physical and mental healthcare.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available on, a 24/7 basis, to provide detained individuals with necessary physical and mental healthcare.
Other
Bedford (2022)
Mental health services in the prison are poor. This is mainly due to staff shortages. We request that the minister review budgets for mental health staff especially in local prisons.
Ministry of Justice
Usk and Prescoed (2023)
Access to specialist mental health facilities remains a problem as the team struggled with low staff numbers.
Ministry of Justice
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Erlestoke (2023)
What action is being taken to ensure that additional healthcare facilities and staff will be provided when the prison’s operational capacity increases?
HMPPS
Wormwood Scrubs (2024)
What further steps will be taken to accurately monitor and reduce the number of therapy and healthcare sessions not attended because of the lack of prison staff (see section 6)?
Governor / Director
Fosse Way (2025)
As identified in 3.1, the health-care provision for getting prisoners to hospital on booked appointments had been erratic and resulted in a number having to be cancelled. Whilst appreciating that staff shortages, bed watches and EE (emergency escorts) are a major contributor to this situation, how will the Director ensure prisoners receive the necessary treatment at the appointed time?
Governor / Director
New Hall (2020)
Healthcare provision should be consistently delivered and sufficient staffing levels maintained to ensure the safety and well-being of prison staff and residents alike.
Governor / Director
Durham (2020)
How can the allocation of officers to the inpatient healthcare centre be made sustainable?
Governor / Director
Yarl’s Wood (2021)
The Board recommends that NHFT continues to maintain the excellent staffing levels and services of the last year.
NHS / Healthcare Provider
Hull (2021)
Improve the management structure of healthcare provision and its communication with prison management.
Governor / Director
Health Investigations (3)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 4b
Health Boards must address immediate staffing pressures while national workforce specifications for maternity services are redeveloped. Health Boards must undertake a comprehensive review of obstetric workforce capacity taking account of service complexity, links with gynaecology, geography, and workforce sustainability. Health Boards should review midwifery and neonatal nursing staffing levels and …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 4a
A multidisciplinary maternity workforce planning tool should be developed and implemented to align and integrate with BAPM standards for neonatal services. This tool should cover the full maternity pathway and include adequate provision for allied health professionals, psychology and pharmacy, as well as services for women with additional social and …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 4d
Should review maternity theatre estate, capacity and staffing to ensure theatres are appropriately located, equipped and resourced for planned and emergency surgery.
wales
Accepted
PHSO Casework Decisions (3)
P-002469 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs A complains about the mental health care and treatment given to her son in the last 20 years.
NHS in England
Feb 2024
P-001917 — South West Yorkshire Partnership NHS Foundation Trust
Mr A complains the Trust did not refer him to secondary psychological treatment until 2019 although he asked for it in 2014.
NHS in England
Not Upheld
Mar 2023
P-002560 — Guy's and St Thomas' NHS Foundation Trust
Mr E complains the Trust’s management of his chronic pain in June 2022 was poor. He says the Trust failed to consider all the options available to manage his pain and continued to insist it could only be managed through pain relief and physiotherapy.
NHS in England
Apr 2024
LGO / SPSO Decisions (39)
PSOW-202104669 — Betsi Cadwaladr University Health Board
Mrs A complained about the care and management her late husband, Dr A, received at Ysbyty Glan Clwyd (“the Hospital”) in April 2020. She said that medical and nursing staff failed to adequately communicate with her about her husband’s condition. Mrs A said that there were also inadequacies and inconsistencies …
PSOW (Public Services Om…
Health
Upheld
Nov 2022
PSOW-202204110 — Cardiff and Vale University Health Board
Mr X complained about his experience as a transgender man accessing the Health Board’s services. He raised concerns about a specific visit to the A&E Department and more general concerns about how the Health Board ensured that its services were inclusive for LGBTQ patients. Mr X felt that a meeting …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202204912 — Cardiff and Vale University Health Board
Mrs X complained that the Health Board had not provided her with a response to the complaint she submitted to it 10months ago. The Ombudsman decided that there had been a delay in the Health Board’s complaint response, which led Mrs X to contact the Ombudsman. She decided to settle …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202403802 — A GP Practice in the area of Betsi …
Ms X complained that the Surgery had failed to contact her to discuss her ongoing health checks and had not responded to the complaint she made in September 2023. The Ombudsman decided that there had been a failure by the Surgery to respond to the complaint and this had caused …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202404725 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to provide a complaint response to her complaint, which she made to it in November 2023. The Ombudsman found that, whilst the Health Board had been in regular contact with Mrs X, it had failed to issue a complaint response. …
PSOW (Public Services Om…
Health
Oct 2024
201102885 — Lanarkshire NHS Board
Mr A was an elderly man with a history of health problems and restricted mobility. He had been nursed at home for several years. Mr A was admitted to hospital with confusion, infection and back pain. Nine days after admission, he developed pressure ulcers. Mr A remained in the hospital …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2012
201406562 — Grampian NHS Board
Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201403869 — Greater Glasgow and Clyde NHS Board - Acute …
Miss C's father (Mr A) was admitted to Glasgow Royal Infirmary from another hospital where he had been admitted earlier following a fall at home. Mr A was admitted to A&E and then moved to a ward. Mr A died several days after his admission. Miss C was concerned that …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201502825 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C complained about the standard of nursing care provided to her mother (Mrs A) during an admission to Glasgow Royal Infirmary. Ms C felt her mother had been over-sedated with morphine when she was not in pain; was denied food; and that staff had labelled Ms C as being …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2015
201501341 — Fife NHS Board
Miss C complained on behalf of her late mother (Mrs A). Miss C complained that Mrs A's dressings were not changed regularly enough, that the board failed to communicate with her regarding how ill her mother was and, in particular, that Mrs A had signed a do not attempt cardiopulmonary …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2015
201501070 — Tayside NHS Board
Mr C complained that while his wife (Mrs C) was a patient in Murray Royal Hospital, she was assaulted by another patient and suffered a minor injury. The staff told him that Mrs C would be protected from the patient. Mrs C was then assaulted again by the patient and …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2015
201508221 — Grampian NHS Board
Miss C complained about the community nursing care provided to her late mother (Mrs A) who was elderly. Miss C said that the community nurse undertook a procedure which caused Mrs A severe distress and brought her to the point of collapse. Miss C said that she and her mother …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2016
201508844 — Lothian NHS Board
Mr C complained about the medical and dental care and treatment he received from the prison health centre. He suffered from severe pain, particularly head and face pain, due to historic injuries and he raised concerns that adequate pain relief was not provided to him and that nursing staff regularly …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2016
201802151 — Highland NHS Board
Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2018
201800220 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Ms A) at Glasgow Royal Infirmary. Ms A was admitted to the hospital on two occasions due to complications from her gastric …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2019
201908610 — Greater Glasgow and Clyde NHS Board - Acute …
C complained to us about the care and treatment provided to their parent (A). A was admitted to Inverclyde Royal Hospital after they had fallen at home. The following night, A had an unwitnessed fall in the hospital. Around ten days later, A's leg was noted to be at an …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2021
201906846 — Forth Valley NHS Board
C complained about the nursing care that they received whilst an in-patient at Forth Valley Royal Hospital. C complained that during their stay in the hospital there were errors in the administration of their medication and that they were manhandled by a member of staff when trying to get out …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2021
202002913 — Fife NHS Board
C complained about the care and treatment their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an …
SPSO (Scottish Public Se…
Health
Upheld
May 2022
202101294 — Fife NHS Board
C complained about the care and treatment provided to their late parent (A) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2023
202106438 — Glasgow City Health and Social Care Partnership
C complained about the care and treatment provided to their parent (A) who had dementia. C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact …
SPSO (Scottish Public Se…
Health and Social Care
Partly Upheld
Sep 2023
202306916 — Tayside NHS Board
C complained about the nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided. We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2024
202306836 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate. C complained …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2024
202209316 — Fife NHS Board
C complained about the care and treatment that their sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2025
202404349 — Highland NHS Board
C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025
202402836 — Borders NHS Board
C complained about the lack of care and understanding for their parent (A) who died in hospital. C referred to incorrect information being passed to the family and the lack of notes and records of events which occurred during A's admission. C said that while the board replied with some …
SPSO (Scottish Public Se…
Health
Aug 2025
202309879 — Forth Valley NHS Board
C’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025
202305480 — Fife NHS Board
C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2025
23-014-851 — Gloucestershire County Council
Summary: The Council failed to complete an Education, Health and Care (EHC) needs assessment within statutory timescales. This delay was, in part, due to a shortage of Educational Psychologists. The Council will make a symbolic payment to Mrs Y and D. The Council will also outline the service improvements it …
LGO (Local Government & …
Education
Upheld
Apr 2024
23-012-356 — Norfolk County Council
Summary: There was fault in how the Council dealt with assessment and care planning for Mr K who is disabled, as well as assessment and support for his mother Ms B. There was fault in how the Council dealt with direct payments, and with recruitment of personal assistants. It has …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
201508595 — Lothian NHS Board
Mr C complained about the care and treatment provided to his wife (Mrs A) when she was admitted to the Western General Hospital for radiotherapy to treat a spinal condition. Mr C said that nursing staff failed to provide reasonable care in relation to the taking of blood samples, pressure …
SPSO (Scottish Public Se…
Health
Not Upheld
Jan 2017
201508664 — Forth Valley NHS Board
Ms C had an operation on a toe of her left foot at Forth Valley Royal Hospital. Ms C's foot was put in a plaster cast and when she returned the following month for it to be changed, a member of staff tried to realign the toe contrary to the …
SPSO (Scottish Public Se…
Health
Feb 2017
201800508 — Highland NHS Board
Mrs C complained about the nursing care that her late mother (Mrs A) received at Broadford Hospital. Mrs C had a number of concerns about the board's record-keeping and also complained about the communication from the nursing staff. Mrs A was admitted to the hospital where a provisional diagnosis of …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2019
201805658 — Highland NHS Board
Miss C complained on behalf of her brother (Mr A) about the care and treatment he received while he was a day patient at a psychiatric hospital. Miss C complained that the hospital wrongly decided to not detain Mr A under the Mental Health (Care and Treatment) Act (Scotland) 2003 …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2019
PSOW-202307593 — Aneurin Bevan University Health Board
Mrs S complained that Aneurin Bevan University Health Board had failed to respond to her complaint, submitted in August 2022. The Ombudsman found that the Health Board had provided a full response to concerns raised by Mrs S in December 2022, but had failed to address the earlier concerns that …
PSOW (Public Services Om…
Health
Feb 2024
20-014-052b — Northern Care Alliance NHS Foundation Trust (20 014 …
Summary: Mr B and Mr C complain about the care their late mother Mrs D received from a Council-funded care home, from district nurses and from a mental health outreach team. They also complain the Council delayed re-assessing her needs. We found the Home failed to properly manage Mrs D’s …
LGO (Local Government & …
Health
Not Upheld
Feb 2022
23-018-187 — Cheshire West & Chester Council
Summary: Miss X complained the Council delayed in carrying out her son’s social care assessment. The Council has now agreed to carry it out within one month. We will not investigate because further investigation is unlikely to achieve anything more. We will not investigate Miss X’s other complaint that the …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
201101678 — Greater Glasgow and Clyde NHS Board
Mrs C had fertility treatment which began in 2008. She had a successful pregnancy in 2009 and in 2011 was invited back for further treatment. On attending the appointment, she was advised there had been an administrative error, and she should not have been invited for further treatment as she …
SPSO (Scottish Public Se…
Health
Upheld
May 2012
25-005-913c — Leicestershire Partnership NHS Trust (25 005 913c)
Summary: We will not investigate Miss X’s complaint about her mother’s care and treatment during September and October 2022. This is because a significant amount of time has passed since the events Miss X is complaining about occurred and it would have been reasonable for Miss X to complain to …
LGO (Local Government & …
Health
Dec 2025
25-005-913b — University Hospitals of Leicester NHS Trust (25 005 …
Summary: We will not investigate Miss X’s complaint about her mother’s care and treatment during September and October 2022. This is because a significant amount of time has passed since the events Miss X is complaining about occurred and it would have been reasonable for Miss X to complain to …
LGO (Local Government & …
Health
Dec 2025