Clinical negligence harms learning
Clinical negligence litigation hindering patient safety learning by focusing on blame rather than system-wide analysis.
5,119 items
11 sources
8 inquiries
Source spread
Where this theme appears
Clinical negligence harms learning has been flagged across 11 independent accountability sources:
63 inquiry recs
193 PFD reports
99 committee recs
5 CQC actions
2 PPO recs
1 NAO rec
1 Scottish FAI
4 Article 2 learning points
1 detention investigation rec
460 PHSO decisions
4290 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 (63) — showing 50 strongest matches
BRIS-119 — Abolish clinical negligence system, establish expert group for alternative patient compensation.
Recommendation: In order to remove the disincentive to open reporting and the discussion of sentinel events represented by the clinical negligence system, this system should be abolished. It should be replaced by an alternative system for compensating those patients who suffer …
Unknown
IHRD-94 — Clinical Negligence Litigation Reform
Recommendation: The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical negligence litigation as it presently operates might be abolished or …
Gov response: Under consideration. No government committee established to date to examine clinical negligence litigation reform.
Accepted in Part
No update 2+ yrs
IHRD-40 — SAI Learning Informing Clinical Audit
Recommendation: Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Gov response: Learning from SAI investigations incorporated into clinical audit programmes.
Accepted
F96 — Information sharing
Recommendation: The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which can be placed on them.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F95 — Information sharing
Recommendation: As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given to allowing the Care Quality Commission access to these reports.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F94 — Evidence-based assessment
Recommendation: As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F93 — NHS Litigation Authority Improvement of risk management
Recommendation: The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F92 — NHS Litigation Authority Improvement of risk management
Recommendation: The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F91 — NHS Litigation Authority Improvement of risk management
Recommendation: The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
IBI-A-7c — Unethical Research Award Amount Review
Recommendation: The Minister consider whether the £10,000 (£15,000 for Treloar's pupils) should in justice be increased and further decides what sum he considers accords most closely with the general public's sense of justice and fairness in respect of an individual being …
Gov response: The Government will consider whether the current unethical research practices award amounts (£10,000 standard, £15,000 for Treloar's pupils) should be increased.
Response Unclear
IBI-A-7b — Wider Definition of Unethical Research
Recommendation: When considering the evidence IBCA applies the wider definition of research explained in the Infected Blood Inquiry Additional Report chapter on Unethical Research.
Gov response: The Government accepts this recommendation in principle and will consult on providing an award for unethical research victims applying the wider definition of research as explained in the Additional Report.
Accepted in Part
In progress
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Unknown
IHRD-48 — Mortality Meeting Recording and Audit
Recommendation: The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Gov response: Mortality meeting recording and audit procedures implemented.
Accepted
IHRD-39 — Investigation Team Reconvening
Recommendation: Investigation teams should reconvene after an agreed period to assess both investigation and response.
Gov response: Follow-up review processes established for SAI investigations.
Accepted
IHRD-38 — Multi-Disciplinary Peer Review
Recommendation: Investigations should be subject to multi-disciplinary peer review.
Gov response: Multi-disciplinary review processes incorporated into SAI investigation procedures.
Accepted
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F115 — Investigations
Recommendation: Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; Subject matter involving clinically related issues is not capable …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F44 — Use of information about compliance by regulator from: Media
Recommendation: Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
BRIS-37 — Urgently review compensation system for medical harm, replacing clinical negligence
Recommendation: There should be an urgent review of the system for providing compensation to those who suffer harm arising out of medical care. The review should be concerned with the introduction of an administrative system for responding promptly to patients’ needs …
Unknown
R38 — Medical record keeping
Recommendation: Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Gov response: Section 4.2 of the Scottish Government's response directly addresses recommendation 38, which relates to clear, accurate, and legible patient records kept by doctors, emphasizing their integral role in good patient care. The General Medical Council …
Accepted
IHRD-68 — Using Investigations for Training
Recommendation: Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
Gov response: Information from investigations and complaints assessed for training purposes.
Accepted
IHRD-67 — Informing Teaching Authorities
Recommendation: Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
Gov response: Mechanisms established for informing teaching authorities of relevant investigation findings.
Accepted
IHRD-66 — Time for SAI Learning
Recommendation: Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
Gov response: Protected time for learning from SAI investigations incorporated into practice.
Accepted
No update 2+ yrs
IHRD-65 — SAI Investigator Training
Recommendation: Training in SAI investigation methods and procedures should be provided to those employed to investigate.
Gov response: SAI investigation training provided to designated investigators.
Accepted
IHRD-57 — Clinical Training for Guidelines
Recommendation: Specific clinical training should always accompany the implementation of important clinical guidelines.
Gov response: Training incorporated into clinical guideline implementation processes.
Accepted
IHRD-49 — Multi-Trust Mortality Meeting Engagement
Recommendation: Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with …
Gov response: Video conferencing facilities provided for multi-Trust mortality meetings.
Accepted
IR2-9 — Status of Awards and Legal Rights
Recommendation: I recommend that, with reference to the status of awards: a) eligible infected and affected persons should not be required to accept the offer of an award in full and final settlement of any right to pursue legal actions related …
Gov response: In line with recommendations 9 and 10 of the Second Interim Report, acceptance of an award does not require applicants to waive their right to pursue litigation. In defined circumstances, if an infected person's condition …
Accepted
IR2-8 — Tariff-Based Compensation Framework
Recommendation: I recommend that the Government should approve a scheme setting out a framework of tariff based compensation for eligible infected and affected persons, at rates which broadly take account of but are not limited by current practice in courts and …
Gov response: In line with recommendation 8 of the Second Interim Report, the Scheme will use a tariff-based framework to calculate the amount of compensation payable to those eligible. In practice, this means that compensation will be …
Accepted
IR2-6 — Categories of Loss and Award Heads
Recommendation: I recommend that the appropriate award in any case should be composed under the following categories of loss, applicable to both eligible infected and affected persons: a) an Injury Impact Award for past and future physical and mental injury, emotional …
Gov response: With respect to recommendation 6 of the Second Interim Report, the Government has accepted the Inquiry's recommended categories of award, and has therefore designed the Scheme to award compensation to include the following: Injury Impact …
Accepted
IR2-4 — Affected Persons Categories
Recommendation: I recommend that the following relevant affected persons should be admitted to the scheme: a) spouses, civil partners and long term cohabitees (for at least one year in the case of the latter) of living or deceased eligible infected persons; …
Gov response: With respect to recommendation 4 of the Second Interim Report, for those who have been affected by this scandal, affected persons will be eligible where their case is linked to that of an eligible infected …
Accepted
IR2-3 — Standard of Proof and Automatic Eligibility
Recommendation: As above, save that (a) the last bullet point should read: "eligibility is accepted if the information available points towards eligibility and the opposite cannot be shown to be more likely" and (b) eligibility should be automatic for individuals already …
Gov response: The Government acknowledges the further distress and trauma that can be caused to those applying for compensation, and so the Scheme has been designed to minimise the burden on applicants whilst protecting against fraud. People …
Accepted
FP16-18 — Academic study requirement
Recommendation: Expert opinion should be informed by proper academic study of the subject.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP66 — Unable to exclude findings
Recommendation: Before a finding of 'unable to exclude' is led in evidence, careful consideration will require to be given to (a) the types of mark for which such a finding is meaningful and (b) the proper interpretation of the finding.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP60 — Disclosure of opinion basis - recording
Recommendation: Experts should record and properly disclose all of the basis of their opinion to enable a court to understand it and the defence to assess it.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP53 — Note-taking general practice
Recommendation: Note-taking as to the detail found on analysis and the process of comparison, though not mandatory, should become the general practice for all fingerprint comparison work.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP-COMPLEX — Complex marks examination
Recommendation: Processes should be developed to ensure that complex marks such as those in question are treated differently, by examination by three suitably qualified examiners who reach their conclusion independently, make notes at each stage, and record reasons for their conclusions.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP9 — Features demonstrable to lay persons
Recommendation: Features on which examiners rely should be demonstrable to a lay person with normal eye sight as observable in the mark.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP5 — Basis of conclusions
Recommendation: Experts should list all variables considered and state whether the conclusion has been reached through training and personal experience or on any other basis such as statistical analysis.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP3 — Discontinue certainty claims
Recommendation: Examiners should discontinue reporting conclusions on identification or exclusion with a claim to 100% certainty or on any other basis suggesting that fingerprint evidence is infallible.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP1 — Fingerprint evidence as opinion
Recommendation: Fingerprint evidence should be recognised as opinion evidence, not fact, and those involved in the criminal justice system need to assess it as such on its merits.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
F232 — Employment liaison officers
Recommendation: The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F231 — Coordination with internal procedures
Recommendation: It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F229 — Revalidation
Recommendation: It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F227 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F226 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F225 — Peer reviews
Recommendation: The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F224 — Information sharing
Recommendation: Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same effect.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F222 — General Medical Council Systemic investigation where needed
Recommendation: The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
IBI-1 — Compensation Scheme
Recommendation: My principal recommendation remains that a compensation scheme should be set up now
Gov response: The Infected Blood Compensation Authority (IBCA) was established through the Victims and Prisoners Act 2024. Scheme regulations came into force August 2024 with first payments made December 2024. As of October 2025, over £1.35 billion …
Accepted
IBI-A-9a — Bereaved Partner Support Scheme
Recommendation: The IBSS cut-off date of 31 March 2025 be reviewed, that the scheme should as soon as possible reinstate support payments to partners bereaved after 31 March 2025 until such time as they receive compensation and that they should have …
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at the 31 March 2025 'cut-off' date for bereaved partners to join an Infected Blood Support Scheme. The …
Accepted
In progress
PFD Reports (193) — showing 50 strongest matches
Phillip Pratt
Concerns: A Root Cause Analysis Investigation Report identified a number of areas of concern arising from the investigation.
Overdue
Ethel Smith Leese
Concerns: Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a care home and new GP practice.
Overdue
Jean Miller
Concerns: District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not issued with thermometers.
Overdue
Ronald Ellwood
Concerns: The provided concerns text is too truncated to identify specific safety issues.
Response (Burton Hospitals NHS Foundation Trust): The Trust plans to refurbish the Air Conditioning Systems within the hospital, re-evaluating environmental conditions and the system design to control the environment with additional heat loads, especially in the …
Responded
David Douglas Hackman
Concerns: After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent death by suicide.
Overdue
Yvonne Sydney Annie Perry
Concerns: A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care unit lacked access to electronic hospital notes, impeding effective treatment.
Overdue
Sally King
Concerns: The provided concerns text is too truncated to identify specific safety issues.
Overdue
Jean James
Concerns: Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.
Overdue
Carol Ann Gibson
Concerns: A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
Overdue
Horace Cottom
Overdue
Kate Louise Pierce
Concerns: A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.
Response (GMC): The GMC acknowledges the concerns but states that statutory rules preclude them from investigating events that are more than five years old and they have not received any further complaints …
Responded
Jennifer Rushworth
Concerns: Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.
Overdue
Anthony Bernard Mcormick
Concerns: Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.
Overdue
Gwilym Pugh Jones
Concerns: Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and …
Responded
Margaret Theresa Corrigan
Concerns: Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.
Overdue
Alva Jullien
Concerns: A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and a 'nil by mouth' decision was made with insufficient evidence.
Overdue
Doris Phoebe Miller
Concerns: Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential patient information.
Overdue
Margaret Easterfield
Concerns: A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Overdue
Charles Bradley
Concerns: Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Overdue
Kerry Jacobs
Concerns: The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Response (Surrey Sussex Healthcare NHS Trust): The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure …
Responded
Michael Anthony
Concerns: The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Response (Guys St Thomas NHS Trust): The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also …
Overdue
Paul Ashton
Concerns: There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to insufficient awareness of specific risks.
Response (Department of Health): NHS England will task its Rare Disease Advisory Group to prepare recommendations within six months for practical steps to improve care for heart transplant patients. NHS England will also ensure, …
Overdue
Karen Peters
Concerns: No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.
Overdue
Mary Wanya
Concerns: Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
Overdue
Abiola Dosunmu
Concerns: Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.
Response (King's College Hospital NHS Foundation Trust): The Trust will refer the case to be included as a reminder in the formal teaching of Foundation doctors and has already shared the incident at departmental governance meetings. ED …
Responded
Ann Bennett
Concerns: The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Overdue
Richard Jaeger-Forzard
Concerns: The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Response (Genie): Genie issued a mandatory Safety Notice requiring recalibration of Z135/70 machines and updated controller software to prevent instability due to miscalibration.
Responded
Frances Bell
Concerns: The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
Overdue
Else Harvey-Samuel
Concerns: Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.
Overdue
Wilfred Aspinwall
Concerns: Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Overdue
John Adams
Concerns: VERONICA HAMILTON-DEELEY, LLB.
Overdue
Esther Jones
Concerns: Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
Overdue
Audrey Daws
Concerns: Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for the patient's condition.
Overdue
Kathleen Cornthwaite
Concerns: The concerns text provided for this report was incomplete, preventing a summary of specific issues.
Overdue
Yahya Khan
Concerns: The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways even when experienced clinicians assess rare conditions.
Overdue
Monique Whitbread
Concerns: A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.
Overdue
Martin Hill
Concerns: No specific concerns were detailed in the provided text for this report.
Response (The Shrewsbury Telford Hospital NHS Trust): The Trust has begun a high-risk review into the death and is improving electronic reporting systems by utilizing a system called "Order Comms" for radiology. The Matron for the CDU …
Responded
Jude Kliem
Concerns: The coroner identified a critical breakdown in communication as a key concern.
Response (Department of Health): NHS England, in partnership with the Paediatric Intensive Care Society, intends to develop a national pro-forma for patient referral and retrieval. Officials will update the Coroner on progress.
Responded
Ann Wells
Overdue
Jackson Mitchell
Concerns: The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.
Response (The Queen Elizabeth Hospital NHS Trust): The Trust conducted an internal review, shared findings at paediatric governance meetings, and introduced a new X-ray review checklist. Regionally, guidelines are being developed (King's Lynn is already following them), …
Overdue
Barrie Lewis
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response: A corrective Action Plan for Improvement was developed, and actions have been taken to improve communication and documentation, including a review of the Care Treatment Plan Policy, a new procedure …
Responded
Bryan Whitby
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response (Central Manchester University Hospital): Central Manchester reviewed the case and presented it at a directorate meeting. The trust implemented an AKI e-alert system trust-wide and conducted teaching sessions for junior doctors on AKI recognition …
Response (Davyhulme Medical Centre): Davyhulme Medical Centre clarified Mr. Whitby's renal function and stated that the NICE guidance on acute kidney injury has been read by all GPs to improve management and awareness of …
Responded
Ronald Smith
Concerns: There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
Overdue
Anthony Geerts
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response (Brighton and Sussex University Hospitals NHS Trust): Brighton and Sussex University Hospitals NHS Trust has integrated the neck of femur service at the Princess Royal Hospital. They also recruited a new Clinical Nurse Practice Educator and implemented …
Overdue
Karen O’Brien
Concerns: The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Overdue
Rachel Hollister
Concerns: The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.
Overdue
Casey Garrett
Concerns: Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.
Response (Health Education East of England): Health Education East of England describes actions planned by Bedford Hospital NHS Trust and the University of Bedfordshire to improve the learning environment for student midwives, including a student forum, …
Overdue
Mary James
Concerns: Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Overdue
Lorraine Bird
Concerns: There was a lack of protocol for assessing patients at the Plaster Room, and a patient was sent home without a medical review despite complaints and possible DVT development.
Response (NHS England): • Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group to develop a pathway for thromboprohylaxis in ambulatory patients requiring temporary limb immobilisation, signed off in September …
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. • NHS Kernow …
Overdue
Eileen Smith
Concerns: The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Response (Department of Health): The response acknowledges the concerns raised and references existing guidance and resources, including work by NHS England, NICE and the NPSA, but describes no specific actions taken or planned by …
Responded
Committee Recommendations (99) — showing 50 strongest matches
#17 —
Recommendation: It is clear to us that in its current form the clinical negligence process is failing to meet its objectives for both families and the healthcare system. Too often families are not provided with the appropriate, timely and compassionate support …
Gov response: 81. We reject this recommendation. The Government does not intend to put in place a Rapid Redress and Resolution Scheme, as explained in the Department’s evidence to the Committee in February 2021. 82. The Department …
Not Addressed
#18 — Significant proportion of clinical negligence compensation payments diverted to claimants' lawyers.
Recommendation: The Department told us that around 19% of the total compensation payments made in 2023–24 by NHS Resolution go to the claimants’ lawyers. This equates to £536 million of the total £2.8 billion paid to claimants in 2023–24 , which …
Gov response: 4.5 The government agrees with the Committee’s recommendation. Target implementation date: to be advised 4.6 The rising costs of clinical negligence claims against the NHS in England are of great concern to government. Costs have …
Not Addressed
#16 — Department's clinical negligence liability reaches £58.2 billion, ranking second largest across government.
Recommendation: The Department recognises an amount for potential future compensation payments for incidents of clinical negligence in its financial statements as a liability. This is reported in the accounts of NHS Resolution and is consolidated into the Departmental Group accounts. The …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2026 4.2 The department and NHS England will continue to prioritise patient safety and a learning culture across the NHS so that harmful …
Not Addressed
#15 — Clinical negligence cases impose significant monetary costs on taxpayers, totalling £2.8 billion.
Recommendation: The Department recognised that each incidence of clinical negligence has a tragedy behind it involving a patient. It told us that while the optimal number of clinical negligence cases would be zero, this will never be a practical target. Clinical …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2026 4.2 The department and NHS England will continue to prioritise patient safety and a learning culture across the NHS so that harmful …
Not Addressed
#4 — Develop a plan to reduce patient harm and manage escalating clinical negligence costs.
Recommendation: It is unacceptable that the Department is yet to develop a plan to deal with the cost of clinical negligence claims, and so much taxpayers’ money is being spent on legal fees. The Department has set aside an astounding £58.2 …
Gov response: The government agrees with the Committee’s recommendation. the department and its partners is taking to reduce patient harm and improve patient safety in the NHS. NHS England is now in the final year of its …
Accepted
#25 — Presumption of private care in clinical negligence awards leads to double public payments.
Recommendation: The government may effectively be paying twice in some instances of clinical negligence, once through the compensation given to claimants and once again through providing NHS treatment and publicly funded social care. Section 2(4) of the Law Reform (Personal Injuries) …
Gov response: The government is keeping this under consideration. Target implementation date: to be advised. 6.2 The existing system requires judges to disregard the availability of NHS services when assessing damages for personal injury. This means claimants …
Response Pending
#24 — Plans to limit lawyer fees for low-value clinical negligence claims are stalled.
Recommendation: The previous government announced plans to place limits on how much lawyers receive from lower damages clinical negligence claims of under £25,000 where 85% of cases fall within this category from April 2024, but 51 Q 50 52 C&AG’s Report, …
Gov response: 5. PAC conclusion: Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. 5b PAC recommendation: The department should: • …clarify its position on a fixed recoverable costs scheme for lower-value …
Response Pending
#23 — Legal costs for low-value clinical negligence claims are disproportionately high compared to damages.
Recommendation: Around three-quarters of clinical negligence claims settle for £25,000 or less, but the legal costs for these claims vastly exceed the damages payable to claimants. In 2024–25, there was a 3.7:1 ratio of claimant and NHS legal costs compared with …
Gov response: 5. PAC conclusion: Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. 5a. PAC recommendation: The Department should: • develop alternative dispute mechanisms to speed up decisions and reduce costs …
Response Pending
#21 — Claimant legal fees for clinical negligence have significantly increased as a proportion of total.
Recommendation: Claimant legal fees have increased in real terms from £148 million in 2006–07 (in 2024–25 prices) to £538 million in 2024–25 and now represent 15% of all settled costs. During the same period, NHS’s legal costs increased in real terms …
Gov response: The Committee’s recommendation is under consideration by the government. Target implementation date: to be advised DHSC, working with David Lock KC, is considering alternative dispute resolution mechanisms and ways to reduce costs for less complex …
Response Pending
#20 — Maternity workforce struggles and poor planning contribute to rising clinical negligence claims.
Recommendation: Evidence from the Royal College of Obstetricians and Gynaecologists suggested that the maternity workforce is struggling under the pressure of delivering increasingly complex care, with more than half of births involving medical intervention, such as a caesarean section or the …
Gov response: 4. PAC conclusion: The Department's failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. 4a. PAC recommendation: The Department and the organisations it funds need to learn …
Accepted
#19 — Long settlement times for child brain injury claims are being addressed by early notification scheme.
Recommendation: NHS Resolution told us it settles around 120 to 130 brain injury cases involving children every year, but historically it has taken an average of 11 or 12 years to settle each claim.43 We asked NHS Resolution what action it …
Gov response: 4. PAC conclusion: The Department's failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. 4a. PAC recommendation: The Department and the organisations it funds need to learn …
Accepted
#18 — Increasing clinical negligence compensation for children driven by legal precedents and long-term care needs.
Recommendation: NHS Resolution told us that harmed children require care costs for decades into the future.37 Damages can include compensation for pain and suffering, care costs, future lost earnings, educational support and accommodation adaptations. They are calculated based on a claimant’s …
Gov response: 4. PAC conclusion: The Department's failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. 4a. PAC recommendation: The Department and the organisations it funds need to learn …
Accepted
#17 — Costs for infant and child injury claims, particularly maternity brain injuries, significantly increased.
Recommendation: Over the last 20 years the cost of settling claims involving infants and children has increased significantly. The highest-value claims are typically those associated with brain injuries suffered in maternity care. In 2024–25, costs for these claims were £1,554 million, …
Gov response: 4. PAC conclusion: The Department's failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. 4a. PAC recommendation: The Department and the organisations it funds need to learn …
Accepted
#11 — Unknown but significant cost of avoidable patient harm to health services.
Recommendation: The cost to health services of treating cases involving clinical negligence specifically or cases of avoidable harm to patients is unknown. The Organisation for Economic Co-operation and Development estimates that treating cases where harm was avoidable costs developed countries 8.7% …
Gov response: 2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2a. PAC recommendation: The Department must set a national framework for improving patient safety with clear targets …
Accepted
#8 — High-value maternity brain injury claims drive significant clinical negligence costs.
Recommendation: NHS Resolution told us that clinical negligence is putting pressure on NHS budgets and is a significant cost to the public purse. The Department told us the reasons for the rising costs were complex. NHS Resolution explained that the increasing …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2026 The rising cost of clinical negligence and experience of patients navigating the system are of great concern to government and ministers are committed …
Response Pending
#7 — Clinical negligence costs have soared and are projected to rise further.
Recommendation: Clinical negligence is the second largest provision on the government balance sheet after nuclear decommissioning. Over the period 2006–07 to 2024–25, the total provision for clinical negligence increased by £45.6 billion in real terms, from £14.4 billion at 31 March …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2026 The rising cost of clinical negligence and experience of patients navigating the system are of great concern to government and ministers are committed …
Response Pending
#1 — Past committees consistently raised concerns about rising clinical negligence costs.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department), NHS England and NHS Resolution on the costs of clinical negligence.1 Our predecessor committees reported …
Gov response: The government disagrees with the Committee’s recommendation. The government has no current plans to publish a separate report of David Lock KC’s work. David Lock KC has been providing ongoing expert advice to Ministers and …
Not Accepted
#4 — Publish the Amos Review and outline concrete plans to reduce maternity care harm and costs.
Recommendation: The Department’s failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. Over the last 20 years the cost of settling claims involving infants and children has increased significantly. In 2024–25, costs for …
Gov response: The government agrees with the Committee’s recommendation. Maternity and Neonatal Investigation will publish its final report and national recommendations in June 2026. This investigation is independent of government. Prior to publishing a final report and …
Accepted
#3 — Establish a national system for sharing and analysing clinical negligence data to improve patient safety.
Recommendation: We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. Behind every clinical negligence claim is a tragic incident of patient harm. We were disappointed …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented This work is underway. NHS England is actively developing and evaluating AI models on Learn from Patient Safety Events (LFPSE) data, including topical analysis and novelty …
Accepted
#17 — Clinical negligence litigation inhibits learning culture and thorough investigations into serious incidents.
Recommendation: It is not within the scope of clinical negligence litigation to encourage the culture, or support the mechanisms, to identify learning from serious incidents. Neither can the process of litigation disseminate learning and enhance patient safety. Moreover, the experience of …
No Published Response
#16 — Clinical negligence litigation hinders patient safety learning, contrasting with no-blame investigations.
Recommendation: Clinical negligence litigation stands in stark contrast to best practice in terms of patient safety. Gains are made by careful system-wide analysis rather than the search for individual blame. The creation of the Health Services Safety Investigations Body as a …
No Published Response
#4 — Establish an independent administrative body to investigate patient harm and determine compensation
Recommendation: The system for compensating injured patients in England is not fit for purpose. It is grossly expensive, adversarial, and promotes individual blame instead of collective learning. We recommend that when a patient is harmed, they or their family should be …
No Published Response
#2 — Clinical negligence system hinders patient safety learning and improvement
Recommendation: Clinical negligence cannot and does not inform or disseminate learning or systematically contribute to patient safety improvements. It is not its purpose and too much information is filtered out at an early stage to ever make this a realistic prospect. …
No Published Response
#10 —
Recommendation: Regarding the provision for clinical negligence, the WGA shows a levelling off of new cases and explains that in the second year of its new strategy to tackle clinical negligence laid out in April 2017, NHS Resolution mediated 380 cases, …
Gov response: 3.3 The Balance Sheet Review, which concluded in November 2020, aimed to strengthen control of long-term risks and the costs of liabilities, to identify opportunities to dispose of assets that no longer serve a policy …
Under Consideration
#22 —
Recommendation: Finally, given their recognition of the role the professional regulators have in ending the blame culture, we recommend that the General Medical Council and the Nursing and Midwifery Council review what changes are required to their remits or working practices …
Gov response: 87. We welcome the Committee’s recommendation that the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) have a role to play in helping to end the blame culture that currently exists in …
Not Addressed
#20 —
Recommendation: We recommend that following that review, the Department brings forward proposals for litigation reforms that award compensation for maternity cases based on whether an incident was avoidable rather than a requirement to prove clinical negligence. That approach would allow families …
Gov response: 85. In order to continue to improve patient safety and address the rising costs of clinical negligence, the Government announced in Spending Review 2020 that it will publish a consultation on these issues. Decisions on …
Not Addressed
#14 —
Recommendation: In addition, we recommend that HSIB shares the learning from its maternity reports in a more systematic and accessible manner. A top level summary of individual cases together with the key learnings derived from them should be shared rapidly across …
Gov response: 64. We accept this recommendation in part. 65. HSIB recognises the importance of sharing learning from their investigations. HSIB has generated substantial data about safety risks in maternity services after having completed over 1700 investigations …
Not Addressed
#17 — Department fails to outline specific actions for reducing patient harm and improving safety.
Recommendation: The previous Committee were concerned that the Department was spending billions of pounds of taxpayers’ money without an effective plan to minimise future costs of the clinical negligence scheme.25 In April 2024, the Committee recommended that, by summer 2024, “the …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2026 4.2 The department and NHS England will continue to prioritise patient safety and a learning culture across the NHS so that harmful …
Not Addressed
#6 — Develop estimates and set out measures to prevent double payment for negligence care.
Recommendation: Clinical negligence claims are settled on the basis of costs of care in the private sector and yet there is nothing to stop the claimant using the NHS or publicly funded social care in the future, potentially inflating the costs …
Gov response: The government is keeping this under consideration. assessing damages for personal injury. This means claimants are able to claim damages for future care costs (for example, including private care) and then go on to use …
Under Consideration
#5 — Develop alternative dispute mechanisms to speed up decisions and reduce costs for less complex claims.
Recommendation: Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. Legal costs in clinical negligence claims have risen sharply, with claimant legal fees increasing in real terms from £148 million in 2006–07 (in 2024–25 prices) to …
Gov response: The Committee’s recommendation is under consideration by the government. mechanisms and ways to reduce costs for less complex cases and speed up resolution. Disproportionate legal costs for low value claims is a key concern in …
Under Consideration
#30 — Clinical negligence framework focused on individual blame hinders early fault admission and settlement.
Recommendation: It is understandable that representatives of injured patients should wish to see fault admitted and cases settled early, but the statutory framework on which clinical negligence is based makes this very difficult. Clinical negligence is focused on individual blame, therefore, …
No Published Response
#22 — An independent administrative system would improve birth injury compensation for patients and families.
Recommendation: An independent administrative system designed in the first instance to provide compensation in birth injury cases would be much more responsive to the needs of patients and families. Without a contentious legal battle, eligibility would be established quickly and support …
No Published Response
#20 — Administrative compensation system improves investigations, requiring formal separation from external regulatory processes.
Recommendation: In the longer term, an administrative compensation system would address problems associated with inadequate investigations by undertaking inquisitorial, system- focused investigations with no examination of individual blame. This would build greater confidence amongst healthcare professionals that they could be open …
No Published Response
#19 — Mandate independent administrative body investigations for alternative dispute resolution and compensation liability.
Recommendation: We further recommend that, in parallel, an investigation by an independent administrative body responsible for alternative dispute resolution should be completed and a determination on liability for compensation released to the family, the Trust and NHS Resolution. The Trust and …
No Published Response
#18 — Reform investigatory system by establishing standardised, time-limited, independent investigations after medical errors.
Recommendation: Aside from the substantive reform of clinical negligence litigation that we have recommended, we also believe that the investigatory system should be reformed. After any tragedy involving medical error there should be a standardised process of investigation which focuses on …
No Published Response
#9 — Administrative compensation system reduces adversarial process and lowers overall costs
Recommendation: The advantage of an administrative system is that criteria can be established to remove uncertainty and turn what otherwise would be an adversarial process into one concerned only with the facts of the case. Compensation should be based on agreement …
No Published Response
#1 — Clinical negligence system requires shift from punitive approach to encourage cooperation and learning.
Recommendation: In 2005 the New Zealand Parliament made a conscious choice to alter the legislation underpinning their system of clinical negligence because they wanted to change from a punitive system to one that would encourage the co-operation of hospitals and medical …
No Published Response
#21 —
Recommendation: HMT acknowledged that clinical negligence had a significant impact on overall levels of compensation in terms of the high amounts paid each year, but noted there would inevitably always be clinical negligence in the health system.47 HMT informed us that …
Response Pending
#20 —
Recommendation: The largest ongoing compensation schemes currently administered by government have paid over £29 billion since 2005 and annual payments from these schemes doubled from £2.5 billion in 2023–24 to £4.9 billion in 2024–25.45 Future liabilities from these schemes were £73.4 …
Response Pending
#19 —
Recommendation: While the review of the negligence system is underway, we recommend the Department must implement the Rapid Redress and Resolution Scheme in full. We also recommend the Department provides the Committee with the scope and timetable for its review of …
Gov response: 86. The Government plans to consult on next steps to address the rising costs of clinical negligence. Decisions on next steps will be taken following the consultation.
Not Addressed
#11 —
Recommendation: Prior to the next scrutiny session, the PHSO should update the Committee on progress against the implementation of the Donaldson Review, outlining how many areas remain outstanding and its proposed steps and timeline to address them. In this update, the …
Gov response: PHSO commissioned Sir Liam Donaldson and Sir Alex Allan in 2018 to review PHSO’s approach to using specialist clinical advice in casework. To date, PHSO has delivered and fulfilled 22 of the 25 recommendations of …
Accepted
#10 —
Recommendation: The Committee notes the progress that has been made to date in implementing the Donaldson Review and look forward to further updates on the implementation of the Review, including an update on the progress of the pilots into systematic investigations.
Gov response: We formally launched PHSO’s Corporate Strategy for 2022–25 on 7 April 2022, and have been holding internal and external stakeholder events to communicate and engage on our plans. This followed a bridging plan during 2021–22, …
Under Consideration
#21 — Maternity and neonatal cases account for 65% of £69.3 billion clinical negligence liability.
Recommendation: NHS Resolution’s 2022–23 accounts include a liability of £69.3 billion to cover the potential costs of clinical negligence. Of this, £45 billion, some 65% of the £69.3 billion total, related to maternity and neonatal liabilities. The Department told us that …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: end of 2024 4.2 Multiple, complex and interrelated factors lead to patient harm during the provision of healthcare. These include: • Organisational factors such …
Accepted
#20 — NHS clinical negligence costs significantly exceed international comparators, lacking litigation trend data.
Recommendation: The Department recognised that each incidence of clinical negligence is a tragedy for an individual and their families.31 They also come with a monetary cost to the taxpayer, in compensation payments for pain suffered and the impact on people’s everyday …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: end of 2024 4.2 Multiple, complex and interrelated factors lead to patient harm during the provision of healthcare. These include: • Organisational factors such …
Not Addressed
#4 — Set out by summer 2024, key reasons and actions to reduce clinical patient harm.
Recommendation: We are concerned that the Department is spending £2.6 billion on clinical negligence payments without an effective plan to minimise future costs of the scheme. Incidences of clinical negligence continue to result in significant cost to the taxpayer, particularly in …
Gov response: The government agrees with the Committee’s recommendation. healthcare. These include: • Organisational factors such as staffing levels, shift patterns and education and training provision; • task factors such as the complexity of medical interventions, processes …
Accepted
#27 — Debate over 1948 Act's private care presumption requires dedicated inquiry into double recovery.
Recommendation: Written evidence from the Medical Defence Union told us that Section 2(4) of the Law Reform (Personal Injuries) Act 1948 is based on a recommendation made in 1946, two years before the establishment of the NHS, which was caveated that …
Gov response: The government is keeping this under consideration. Target implementation date: to be advised. 6.2 The existing system requires judges to disregard the availability of NHS services when assessing damages for personal injury. This means claimants …
Response Pending
#31 — Ensure adequate hospital staff are trained in 'just culture' to reduce confrontation and breakdown.
Recommendation: NHS staff, injured patients and families need greater support in dealing with the fallout from clinical negligence cases. We recommend that every hospital should have adequate numbers of staff trained in “just culture” practices to reduce confrontation and relationship breakdown …
No Published Response
#27 — Transition to an administrative system to avoid intensive legal support and lottery of representation.
Recommendation: In the system we recommend, someone with a claim would not need intensive legal support as their claim would be evaluated inquisitorially without months or years of toil to demonstrate clinical negligence. It is also important to note that there …
No Published Response
#25 — Make litigation an option for claims only after pursuing the administrative system first.
Recommendation: Therefore, we recommend that litigation should become an option for claims covered by the administrative system only after the claimant has pursued their case through the administrative system.
No Published Response
#24 — Patients prefer simpler administrative compensation, which should be the mandatory first port of call.
Recommendation: Although our system would be no less generous in its awards than the courts, patients would still retain the option of pursuing clinical negligence cases and seeking redress via litigation. Evidence from abroad indicates, however, that when given the choice, …
No Published Response
CQC Inspection Actions (5)
Psychiatry-UK LLP
The service should ensure there are mechanisms in place to learn from near misses.
Should Do
Psychiatry-UK LLP
The service must ensure learning from near misses or incidents is consistently communicated to all staff.
Must Do
Bousfield Surgery
Improve the management of significant events and complaints by providing appropriate training to the person responsible for the investigation and documentation of significant events and complaints.
Should Do
Billet Lane Medical Practice
Takeactiontorecordthereviewsofsignificanteventsatclinicalmeetingsandcompleteasignificanteventlog.
Should Do
Affinity Trust Specialist Support Division North
The provider had failed to ensure learning was used to inform improvements associated with risk and the provision of people care.
Must Do
PPO Death in Custody Recommendations (2)
The Governor of HMP Woodhill
The Governor of Woodhill should share this report with the Deputy Governor and CM A and discuss the Ombudsman’s findings with them.
The Head of Healthcare
ensure that a copy of this report is shared with Dr A, and that his employing agency discusses the Ombudsman’s findings with him.
Scottish Fatal Accident Inquiries (1)
Article 2 Learning Points (4)
— LP 17
The prison should develop a robust method for investigating serious untoward incidents using root cause analysis methodology.
HMP Altcourse
Partially Accepted
— LP 2
I recommend that NHS England and NOMS: take note of the findings in Chapter 11, and consider jointly in the light of this investigation whether the lessons of this investigation have a wider application; in particular, that they consider whether they are satisfied that adequate arrangements are now in place …
NHS England, NOMS
— LP 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and …
HMP Lincoln, HMP Ranby
— LP 6
We recommend that HMPPS and the Governor of HMP Chelmsford review current policy and practice to ensure that it is clear that compliance with national and local policies following an incident of serious self-harm does not replace the general duty under PSO 1300 to commission a formal investigation of a …
HMPPS
Accepted
PHSO Casework Decisions (460)
P-004684 — An independent provider in the Newcastle-under-Lyme area
Mrs H complains about the Trust failed to remove her left ovary during a left oophorectomy.
NHS in England
Jan 2026
P-001208 — A hospital in the Leeds area
Mrs I complains about an intrauterine system insertion and biopsy procedure at a hospital in the Leeds area in January 2020.
NHS in England
Upheld
Sep 2021
P-001183 — University Hospitals Birmingham NHS Foundation Trust
Mrs E complained that University Hospitals Birmingham gave her the wrong type of plaster after surgery on her foot, meaning she was unable to have a boot fitted. Mrs E complained that this meant she had to use a walking frame, which led to damage to her right leg.
NHS in England
Partly Upheld
Nov 2021
P-001198 — Imperial College Healthcare NHS Trust
Mrs H complains about the angiogram her husband, Mr H, had at Imperial College Healthcare NHS Trust (the Trust) on 19 February 2019. She complains the procedure failed and did not alleviate her husband’s transplant artery blood clot, and caused him pain and discomfort and prevents him from having a …
NHS in England
Nov 2021
P-001200 — Birmingham Women's and Children's NHS Foundation Trust
Miss I complained that she developed a fistula which resulted in a colostomy bag being fitted, following an operation at the Trust for a rectocele prolapse.
NHS in England
Partly Upheld
Nov 2021
P-001231 — Queen Victoria Hospital NHS Foundation Trust
Ms R complains the Queen Victoria Hospital NHS Foundation Trust failed to place the correct lens when she had cataract surgery on her right eye in September 2019.
NHS in England
Dec 2021
P-001554 — University Hospitals Bristol and Weston NHS Foundation Trust
Ms A complains that following heart surgery doctors left a stitch in which caused an infection.
NHS in England
Sep 2022
P-001552 — Barts Health NHS Trust
Mr E complains on behalf of his wife, Mrs E following an operation in 2012 during which her bowel was cut. Mrs E also complains about the Trust’s complaints handling and that they did not investigate or provide a response to all her questions.
NHS in England
Sep 2022
P-001551 — A medical practice in the Gateshead area
Miss E complains her GP snapped her contraceptive coil while trying to remove it. She experienced severe pain and heavy bleeding and was admitted to hospital with a pelvic infection.
NHS in England
Sep 2022
P-001547 — Medway NHS Foundation Trust
Mrs Y complains that the Trust damaged her artery during an operation and that they did not conduct an appropriate scan when she complained of pain months later.
NHS in England
Sep 2022
P-001904 — Countess of Chester Hospital NHS Foundation Trust
Ms E complains a previous procedure with her contraceptive coil led her to develop a serious infection and to have life-changing surgery. She also says the Trust ignored her and did not respond to her complaint.
NHS in England
Mar 2023
P-001985 — Moorfields Eye Hospital NHS Foundation Trust
Mrs A complains the Trust did not do her cataract operation properly, there was a complication and it meant she needed more surgery. She says this left her with a poor outcome.
NHS in England
May 2023
P-002001 — A dental practice in the Lewisham area
Ms A complains the Practice extracted the wrong tooth and failed to provide good aftercare.
NHS in England
May 2023
P-001980 — University Hospitals of Derby and Burton NHS Foundation …
Mr A complains the Trust burned his back during a jaw operation in December 2020. He also complains it did not give him appropriate aftercare.
NHS in England
May 2023
P-002023 — London North West University Healthcare NHS Trust
Ms T complains the Trust did not do surgery correctly to remove abnormal cells in her cervix as it led to heavy vaginal bleeding. She also complains it prescribed her with clindamycin (an antibiotic) to which she was allergic.
NHS in England
Jun 2023
P-002392 — Leeds Teaching Hospitals NHS Trust
Mr E complains the Trust delayed diagnosing his wife's cancer, caused internal damage during an operation, did not properly manage his wife’s hygiene, failed to give medication to his wife, failed to stop blood thinning medication before a planned operation and lost his wife’s wedding and engagement rings.
NHS in England
Jan 2024
P-002472 — An independent provider in the Buckinghamshire area
Mrs O complains the Service did not provide skeleton mould hearing aids, damaged her right eardrum causing an infection and failed to provide her with an appropriate appointment.
NHS in England
Feb 2024
P-002471 — King's College Hospital NHS Foundation Trust
Ms J complains that the Trust used the wrong arm to draw blood and insert a drip line, failed to report this as an incident and let her catheter overfill.
NHS in England
Feb 2024
P-002589 — South Tees Hospitals NHS Foundation Trust
Mr E complains about various aspects of the care and treatment clinicians at a hospital gave to his wife in the last two months of her life. He believes failings by clinicians could have contributed to his wife’s death.
NHS in England
Upheld
Apr 2024
P-002582 — A dental practice in the Bury area
Mrs M complains the dentist did not carry out the procedure properly in July 2023, when extracting the teeth from her lower jaw.
NHS in England
May 2024
P-002753 — A dental practice in the Westmorland and Furness …
Miss H complains the dental practice removed the wrong tooth.
NHS in England
Jul 2024
P-002744 — A dental practice in the City of Leicester …
Miss A complains the Practice incorrectly removed a tooth on 9 October 2023.
NHS in England
Jul 2024
P-002752 — A practice in the City of Derby area
Mr and Mrs R complain about the care and treatment the Trust provided during Mrs R's pregnancy and the birth. They complain the staff did not direct Mrs R to services, it did not support her to write a birth plan and staff did not tell her what was happening, …
NHS in England
Partly Upheld
Jul 2024
P-003285 — Warrington and Halton Hospitals NHS Foundation Trust
Miss E complains about the Trust’s treatment during her labour in October 2021. She complains staff ignored her wishes and gave her medical procedures without her consent.
NHS in England
Upheld
Jul 2024
P-002870 — Nottinghamshire Healthcare NHS Foundation Trust
Mr E complains the Trust neglected his mental health care between December 2022 and April 2024.
NHS in England
Aug 2024
P-002895 — Northumbria Healthcare NHS Foundation Trust
Mrs O complains the Trust did not refer her for an early pregnancy scan, or tell her she could self-refer to this service. She also complains the Trust's first response to her complaint contained conflicting information.
NHS in England
Upheld
Aug 2024
P-002907 — South Central Ambulance Service NHS Foundation Trust
Miss A complains about the lack of care the Trust gave to her son in April 2023.She says the ambulance crews failed to provide any treatment or take any clinical observations and her son’s capacity to make these decisions was compromised.
NHS in England
Aug 2024
P-002861 — University Hospitals Sussex NHS Foundation Trust
Miss and Mrs Q complain that staff stopped Mr Q's medication and delayed in setting up a syringe driver when Mr Q was on the end of life pathway.
NHS in England
Aug 2024
P-002880 — Bedfordshire Hospitals NHS Foundation Trust
Miss Y complains the Trust delayed in diagnosing her mother's fractured pelvis, about poor management of a gastric bleed and a delay in monitoring her mother's atrial fibrillation.
NHS in England
Aug 2024
P-002863 — Homerton Healthcare NHS Foundation Trust
Mrs L complains about aspects of the care and treatment clinicians at a hospital gave to her mother. She is particularly concerned about how they managed anticoagulation. She is also concerned about a lack of dementia care.
NHS in England
Partly Upheld
Aug 2024
P-002876 — Warrington and Halton Hospitals NHS Foundation Trust
Mr P complains about the care he received at the Trust during an admission in November 2022. He complains staff gave him flucloxacillin despite him being allergic to it. He also complains about the nursing management of dressings for his skin condition.
NHS in England
Partly Upheld
Aug 2024
P-002838 — A practice in the North West London area
Miss A complains about the care provided to her mother, Mrs B, by the Practice for her cough symptoms between June 2021 to July 2022.
NHS in England
Aug 2024
P-002883 — A practice in the Solihull area
Miss A complains the Practice failed to identify that she had a lump in her breast at an appointment in January 2023.
NHS in England
Aug 2024
P-002841 — Shrewsbury and Telford Hospital NHS Trust
Mr W complains the Trust did not appropriately treat his wife for food poisoning before her death.
NHS in England
Partly Upheld
Aug 2024
P-002896 — A practice in the Tameside area
Miss H complains on behalf of herself and her son that the Trust did not diagnose his pyloric stenosis in July 2023. She also complains that the Practice should have suspected the condition and referred her son.
NHS in England
Aug 2024
P-002903 — Sheffield Teaching Hospitals NHS Foundation Trust
Mr K complains about the care and treatment provided to his sister. He complains the Practice failed to recognise the deterioration in her ability to care for herself and to put appropriate referrals in place after she fell at home.
NHS in England
Partly Upheld
Aug 2024
P-002873 — Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation …
Mrs T complains that the Trust failed to take account of her husband’s history of peptic ulcers when he was admitted to hospital in September 2022. She says the Trust should have done a gastroscopy but failed to. Mrs T also complains about the way the Trust handled her complaint.
NHS in England
Aug 2024
P-002788 — University Hospitals of Leicester NHS Trust
Ms S complains about the care and treatment her son received when he was admitted to hospital with unexplained neurological symptoms.
NHS in England
Aug 2024
P-002853 — A practice in the City of Bristol area
Miss F complains a GP misdiagnosed her mother’s symptoms and did not arrange suitable investigations or treatment, which contributed to her death.
NHS in England
Aug 2024
P-002897 — North Tees and Hartlepool NHS Foundation Trust
Ms K complains about the care and treatment North Tees and Hartlepool NHS Foundation Trust provided to her mother, Mrs K, during her admission between and May June 2023.
NHS in England
Aug 2024
P-002905 — University Hospitals Dorset NHS Foundation Trust
Mr and Mrs B complain about the Trust's care and communication when their first trimester scan showed abnormalities. They are concerned that delays treating Mrs B’s urinary tract infection may have caused their pregnancy loss.
NHS in England
Partly Upheld
Aug 2024
P-002887 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss B complained about inadequate assessments and investigations when she had symptoms of a brain bleed, a delay in diagnosis, how her pain was managed and about poor nursing care and complaints handling.
NHS in England
Partly Upheld
Aug 2024
P-002920 — A practice in the Newcastle upon Tyne area
Ms D complains about aspects of the care clinicians at two different hospitals from the same Trust gave to her mother in 2020. She is especially concerned about whether doctors delayed diagnosing a neuromuscular condition which led to her mother’s death a year later.
NHS in England
Partly Upheld
Sep 2024
P-002949 — A practice in the Greenwich area
Miss D complains about the care four different organisations gave to her mother before and after her cancer diagnosis. She believes her mother should have had treatment sooner that could have prevented her death.
NHS in England
Not Upheld
Sep 2024
P-002961 — Maidstone and Tunbridge Wells NHS Trust
Mrs F complains about the care and treatment the Trust gave to her father between 2018 and 2021. Mrs F complains the Trust did not act when it should have done, it did not do appropriate investigations and it failed to give her father summary letters after his six monthly …
NHS in England
Upheld
Sep 2024
P-003004 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs T complains the Trust failed to diagnose her husband with cancer, resulting in his death.
NHS in England
Sep 2024
P-002959 — Lewisham and Greenwich NHS Trust
Mrs N complains that the Trust did not diagnose her with ovarian cancer. She also complains about the Trust’s complaint handling.
NHS in England
Upheld
Sep 2024
P-002935 — United Lincolnshire Hospitals NHS Trust
Mrs L complains her husband suffered a bleed and unrecoverable collapse after a routine procedure at the Trust.
NHS in England
Upheld
Sep 2024
P-002937 — A practice in the Birmingham area
Mrs F complains staff did not promptly investigate her son’s seizures and they delayed finding his cancer. She also complains staff did not support his hygiene and skincare needs in hospital, and they did not manage his broken arm properly.
NHS in England
Not Upheld
Sep 2024
P-002921 — King's College Hospital NHS Foundation Trust
Mr P complains the Trust did not do the right tests on his brother to check if his brain tumour was cancerous or consider information from tests done before. He also says the Trust did not properly monitor the tumour, it missed opportunities to recognise the cancer and treat it …
NHS in England
Upheld
Sep 2024
LGO / SPSO Decisions (4290)
PSOW-202005974 — Swansea Bay University Health Board
Mrs A complained about the Health Board’s management of her miscarriage (pregnancy loss) in January2020. Mrs A said that the Health Board failed to identify her miscarriage when she first presented with symptoms, to carryout an ultrasound scan to confirm that the miscarriage had fully completed, to advise her when …
PSOW (Public Services Om…
Health
Upheld
Jul 2022
201609388 — Lothian NHS Board - Acute Division
Mr C complained about the care and treatment his late wife (Mrs A) received during admissions to St John's Hospital, the Royal Infirmary of Edinburgh and the Western General Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing Mrs A's lymphoma (a type of cancer) during those …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2018
201609128 — A Medical Practice in the Grampian NHS Board …
Mr C complained that the practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2018
201608679 — A Dentist in the Tayside NHS Board area
Miss C complained about the treatment a dentist provided to her over a number of years. We took independent advice from a dental adviser. We found that there was a failure by the dentist to observe decay in three teeth, and possibly other teeth. Consequently, the dentist failed to plan …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2018
201608505 — Highland NHS Board
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Ms C complained that Mr A did not receive a reasonable standard of surgical care and treatment when he was admitted to Raigmore Hospital for an operation. During the operation, Mr A …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2018
201608303 — A Health Board
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that the board did not take appropriate action in relation to an ulcer on Mrs B's daughter (Ms A)'s heel. Ms A had a number of complex health …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2018
201607981 — Greater Glasgow and Clyde NHS Board
Ms C, who works for an advocacy agency, complained on behalf of her client (Ms A). Ms C complained that Ms A did not receive a reasonable standard of psychiatric care and treatment when she was admitted to the Royal Alexandra Hospital. Ms A had been unwell and when she …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2018
201703718 — A Medical Practice in the Forth Valey NHS …
Mrs C complained about the care and treatment given to her late father (Mr A) by the practice. Specifically that, during the three years prior to a diagnosis of a very rare form of cancer, there were failures to take action on his symptoms, not all tests that were due …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
201702191 — A Health Board
Mr C complained about the care and treatment his late father (Mr A) received at the Royal Alexandra Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing and treating Mr A's metastatic melanoma (skin cancer that has spread). Mr C also complained about a failure to communicate …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
201702071 — Lothian NHS Board - Acute Division
Mr C complained about the care and treatment provided to his father (Mr A) at the Western General Hospital. Mr C complained that there was a delay in the board diagnosing Mr A's non-Hodgkin's lymphoma (a form of blood cancer), and that the board did not follow-up his complaint in …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
201701880 — Dumfries and Galloway NHS Board
Mrs C complained on behalf of her husband (Mr A) about the care and treatment he received at Dumfries and Galloway Royal Infirmary. Mr A became unwell and was admitted to hospital. A heart scan identified that he had a gathering of fluid around his heart. Staff inserted a chest …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
201608947 — Tayside NHS Board
Mr C complained about the care and treatment that his father (Mr A) received at Perth Royal Infirmary following a fall. Mr C was concerned that a fracture was not identified until Mr A had been in hospital for eight days. Whilst in hospital, Mr A also suffered a period …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
201608902 — A Medical Practice in the Fife NHS Board …
Mr C transferred to the practice from another practice and, on first attendance at the new practice, was prescribed Sertraline (an anti-depressant medication used to treat anxiety). However, he suffered side effects as a result of this prescription. He was of the opinion that this would have been immediately obvious …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
PSOW-202001338 — Betsi Cadwaladr University Health Board
Ms X complained about the treatment her father, Mr Y received for multiple myeloma (a type of bone marrow cancer) between January and March 2020. In particular she complained about the appropriateness of the decision making around monitoring and stopping 2nd line treatment, the failure to commence 3rd line treatment …
PSOW (Public Services Om…
Health
Upheld
Jul 2021
PSOW-202001692 — Cwm Taf Morgannwg University Health Board
Mr A complained about the care given to his late aunt, Ms B, by Cwm Taf Morgannwg University Health Board (“the Health Board”) after her admission to hospital, with pelvic injuries, following a fall. He said that the Health Board failed to reassess the status of Ms B’s lung cancer …
PSOW (Public Services Om…
Health
Upheld
Jul 2021
PSOW-202003081 — Swansea Bay University Health Board
Mrs A complained about the Health Board’s (“the Health Board”) management of her labour in March 2020 after a scan found that that her baby was large for the due date. Mrs A said the Health Board failed to counsel her properly about options for the birth, to listen to …
PSOW (Public Services Om…
Health
Upheld
Jun 2022
201200269 — A Dentist in the Ayrshire and Arran NHS …
Mr C complained about the care and treatment provided by his dentist in 2010. He said that a denture and replacement filling were not completed properly, and that an existing cavity (area of decay) was not discovered and/or treated. We upheld Mr C's complaint, as our investigation found that the …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2012
201200268 — A Dentist in the Ayrshire and Arran NHS …
Mr C complained about the care and treatment received from his dentist, including that: a root canal treatment was not completed properly; despite requesting a white filling the filling provided was grey; the dentist allowed bleach from a syringe to spill on to Mr C's suit and allowed the syringe …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2012
201200160 — Forth Valley NHS Board
Mr C complained about the care and treatment given to his late wife (Mrs C). He said that Mrs C had initially been taken into hospital with a urinary tract infection. The following month, she was transferred to another hospital for rehabilitation and physiotherapy. Later that month she was noted …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2012
201203178 — A Dentist in the Highland NHS Board area
Mr C said that when he consulted his dentist for the first time, she carried out an initial examination and told him he required six fillings. Three of these were carried out nine days later, but when Mr C returned to to have the remainder of the work done, he …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201203099 — Borders NHS Board
Ms C has type 2 diabetes. In July and August 2012 she attended, or was admitted to, hospital five times with swollen, painful legs. Deep venous thrombosis (DVT - a blood clot in a vein) was discounted and she was ultimately diagnosed as having cellulitis with some pitting oedema (an …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201202435 — A Medical Practice in the Ayrshire and Arran …
Mr C's daughter (Miss A) who was three years old, was taken to her medical practice because she was vomiting. Mr C complained that GPs there failed to appropriately investigate Miss A's symptoms and that this led to a delayed diagnosis of a brain tumour. Miss A's parents had taken …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201202323 — Tayside NHS Board
Mrs C attended the board's dental service, as her dentures were loose and uncomfortable. She had a new lower denture fitted and her top denture relined. However, she found the new dentures uncomfortable from the outset and returned to the service. The dentist made her a new lower denture based …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201202231 — Forth Valley NHS Board
Ms C complained about the treatment her daughter (Miss A) had received from the Child and Adolescent Mental Health Service (CAMHS). She said that they had not responded soon enough when she and her daughter had expressed concerns about Miss A. Miss A experienced a significant deterioration in her eating …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201201725 — Lanarkshire NHS Board
Mr C complained on behalf of his father (Mr A) about the care and treatment he received when he was admitted to hospital three times over a period of about eleven days. Mr A had a history of high blood pressure and arthritis, as well as a history of heavy …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201201885 — Dumfries and Galloway NHS Board
Mr C complained that the board unreasonably delayed in diagnosing that his late wife (Mrs C) had mesenteric ischemia (reduced blood flow to the intestines). He also complained that they delayed in operating on Mrs C following her diagnosis and that this caused her death. We took independent advice from …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2013
201201225 — Lanarkshire NHS Board
Mrs C complained about the care and treatment given to her late mother (Mrs A) in hospital over a two day period. Mrs A was elderly, had been unwell and was deteriorating. Mrs C said she had spoken to her mother by phone late on the afternoon of the first …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2013
201200696 — Ayrshire and Arran NHS Board
Mr A was in hospital for four months, and his daughter (Ms C) was unhappy about aspects of his nursing care during that time. Mr A was prescribed a low dose of madopar (a drug used to treat Parkinson's disease), which was increased two weeks later. The medical records show …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2013
201204362 — A Medical Practice in the Lothian NHS Board …
Ms C complained on behalf of her daughter (Ms A), an overseas student who was studying in Scotland. Ms A had developed abdominal pain, nausea and constipation. She was seen at home by a GP who examined her, carried out a urine analysis and advised her to take an over-the-counter …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2013
201204084 — Dumfries and Galloway NHS Board
Mr C complained on behalf of his son (Mr A). Mr A had mental health problems but although he was twice on the waiting list for treatment for this, the board removed him from the list because he was either being investigated by the police or was awaiting trial. Mr …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2013
201100377 — Greater Glasgow and Clyde NHS Board - Acute …
Miss C's mother (Mrs A) was admitted to hospital for surgery. Her recovery took a long time and she developed pleural effusions (fluid that gathers around the outside of the lung). After about four months she was transferred to another hospital. At this time she was still very unwell, being …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2013
201301063 — Lanarkshire NHS Board
Mrs C complained about the care and treatment the board provided to her late husband (Mr C) before his death. Mr C had been diagnosed with bladder cancer, and also had heart disease, diabetes, high blood pressure and arthritis. His bladder cancer was managed through intravesical BCG treatment (a vaccine …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201300910 — A Medical Practice in the Fife NHS Board …
After Mr C's daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP, who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201300547 — Lothian NHS Board
Miss C and her mother complained about the care and treatment provided to Miss C's late father (Mr A) after he attended hospital for a day-case urology procedure (urology is a specialty in medicine that deals with problems of the urinary system and the male reproductive system). He had been …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201300332 — Ayrshire and Arran NHS Board
Mrs C complained about the care and treatment that the board provided to her late mother (Mrs A) before she committed suicide. Mrs A had been admitted to hospital with low mood and worsening anxiety. She had a diagnosis of recurrent depressive disorder and a history of drug overdoses dating …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2014
201205348 — Forth Valley NHS Board
Mr C, who is a prisoner, complained to us about the board's handling of his complaint to them about healthcare issues. We were satisfied that the board had considered and responded to the issues Mr C raised, but our investigation found that they had failed to deal with the complaint …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
201205200 — Lothian NHS Board
Ms C was a voluntary patient at the board's eating disorders unit. Some four months after she first attended there, the clinician responsible for her overall care told her that he intended to apply for a Compulsory Treatment Order (CTO - an order that allows professionals to treat a person's …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2014
201204944 — Fife NHS Board
After Mr C's daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP, who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
201204873 — Lanarkshire NHS Board
Mr C's late mother (Mrs A), who suffered from dementia, was admitted to hospital with hip pain after a fall. X-rays suggested that she had fractured a bone in her pelvis. Healthcare professionals assessed her as having moderate cognitive impairment (a condition affecting the ability to think, concentrate, formulate ideas, …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
201204779 — Highland NHS Board
A Member of Parliament (Mr C) complained to us on behalf of Mr and Mrs A whose daughter (Ms A) died from skin cancer. Mr and Mrs A felt that their daughter's diagnosis and treatment was unreasonably delayed because a mole was not properly removed from her scalp four years …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2014
201204705 — A Medical Practice in the Greater Glasgow and …
Mrs C's father (Mr A) has a complex medical history, including cancer. Early in 2012, Mr A began to suffer backache, and a GP visited him at home. The GP believed the problem was musculoskeletal and prescribed anti-inflammatory gel and pain relief (tramadol). Mr A continued to suffer a great …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
201304679 — A Medical Practice in the Lothian NHS Board …
Mrs C went to her medical practice because she had been having headaches for a few months. She was given migraine medication to try, and an appointment was made for her to come back a week later. Mrs C did not go to the appointment but had called NHS 24, …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2014
201304268 — A Medical Practice in the Tayside NHS Board …
Ms C said that she had a contraceptive implant fitted and when it was near the end of its life, she attended her GP for a replacement. She complained that she was told that because of her high blood pressure (BP) it was not possible to do so. As it …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2014
201302916 — Greater Glasgow and Clyde NHS Board
Ms C, who is an advocacy worker, complained on behalf of her client, Mrs A. Mrs A went to her dentist with toothache. She was examined, but decided not to have treatment because of the complexity of the problems. Early the next month, the dentist referred Mrs A to the …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2014
201306095 — Lothian NHS Board
Mr C, who is a prisoner, fell and injured his hand. He complained that, after seeing the doctor the following day, he had to wait a further five days to be taken for an x-ray. In responding to his complaint, the board advised that his referral was treated as non-urgent, …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2014
201400621 — Fife NHS Board
Mrs C was suffering from pain in her thigh some time after having a hip replacement, and her GP referred her for an x-ray. The report of the x-ray noted that there was no abnormality, but that there were also no previous images available for comparison as Mrs C's earlier …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2014
201400585 — Lothian NHS Board
Mr C's wife (Mrs C) suffered from severe liver disease, and was admitted to, and discharged from, the Royal Infirmary of Edinburgh three times in a three-month period. Shortly after her last discharge, Mrs C was admitted to the Western General Hospital, where she passed away about a week later. …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2014
201400583 — Highland NHS Board
Ms C, who is an advice worker, complained on behalf of her client (Ms A) about her care and treatment. Ms A's GP referred her to Raigmore Hospital because she had been experiencing backache, painful urination and pain in her thighs, and she was admitted as an emergency. She was …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2014
201400540 — A Medical Practice in the Greater Glasgow and …
Mrs C, who is an advice worker, complained on behalf of her client (Mr A) that his medical practice had failed to properly assess his symptoms and provide him with further tests to determine his increased risk of stroke. Mr A had attended the practice on a number of occasions …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2014
201400384 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C, who is an advice worker, complained on behalf of her client (Mr A) about the care and treatment of his late mother (Mrs B). Mrs B was admitted to Glasgow Royal Infirmary with pain in her side and was found to have a kidney stone. She began taking …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2014