Complaint record keeping failures
139 items
2 sources
Failures in maintaining accurate and procedural records for managing complaints in residential care homes.
Cross-Source Insight
Complaint record keeping failures has been flagged across 2 independent accountability sources:
75 inquiry recs
64 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (75)
BAHA-17 — CPErS Complaints Procedure
Recommendation: JDP 1-10 should incorporate the requirement that on entry to and exit from a theatre level detention facility, CPErS are proactively asked whether or not they have any complaints concerning their treatment. This should not be done in the presence …
Gov response: Accepted. Procedures for proactively seeking CPErS complaints have been incorporated into doctrine.
Accepted
Delivered
BAHA-37 — Occurrence Book Requirement
Recommendation: A suitable occurrence book must be maintained at all times whenever CPErS are being held at a unit or sub-unit holding facility.
Gov response: Accepted. Occurrence book requirements have been mandated for all CPErS holding facilities.
Accepted
Delivered
BAHA-54 — MATT 7 Take-up Recording
Recommendation: There needs to be better recording of the take-up of MATT 7 (and equivalent training) to avoid the need to rely upon Reception Staging and Onward Integration (RSOI) training in CPErS handling.
Gov response: Accepted. Better systems for recording MATT 7 completion have been implemented.
Accepted
Delivered
R1 — Prison records retention
Recommendation: Given what we discovered about the destruction of prisoners' files, many of which would have been important historical records, we recommend that the SOSNI should satisfy himself whether any other prison records have been destroyed and whether proper retention processes …
Gov response: Secretary of State Owen Paterson stated on 14 September 2010 that he would discuss all three recommendations with Justice Minister David Ford, as prisons had become a devolved matter. The inquiry had found that approximately …
Accepted
BRIS-35 — Create a 'one-stop shop' system in every trust for patient concerns
Recommendation: There should be a clear system, in the form of a ‘one-stop shop’ in every trust, for addressing the concerns of a patient about the care provided by, or the conduct of, a healthcare professional.
Unknown
BRIS-36 — Establish independent, swift, and thorough complaints handling with advocacy for patients
Recommendation: Complaints should be dealt with swiftly and thoroughly, keeping the patient (and carer) informed. There should be a strong independent element, not part of the trust’s management or board, in any body considering serious complaints which require formal investigation. An …
Unknown
13 — Quarterly auditing of Rule 40 and Rule 42 use
Recommendation: The Home Office must regularly (and at least quarterly) audit the use of Rule 40 and Rule 42 across the immigration detention estate, in order to identify trends, any training needs and required improvements. In addition, HM Inspectorate of Prisons …
Gov response: The DSO revision includes compliance auditing across the detention estate. This recommendation was also directed at HMIP and the IMB Management Board.
Accepted in Part
No update 2+ yrs
22 — Update healthcare complaints handling guidance
Recommendation: The Home Office must review and update Detention Services Order 03/2015: Handling of Complaints to ensure that appropriate guidance is given to healthcare providers on the investigation and handling of complaints specific to the provision of healthcare in an immigration …
Gov response: A comprehensive review of complaints processes, including medical complaints, is underway. Detention Services Orders are to be updated on completion.
Accepted in Part
Delivered
CR17 — Protocol for duty to assist referrals
Recommendation: HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold for making a referral on a potential breach by a …
Response Pending
DM-21 — Review archiving processes for historic material
Recommendation: In order to avoid most of the delays and difficulties inherent in this case, and in so many other unsolved cases, there is a need for a review of the processes for archiving historic material with a view to creating …
Gov response: The current Home Secretary will subsequently approve a new Code of Practice on Police Information and Records Management to replace the existing Code of Practice on Management of Police Information 2005, and it will soon …
Accepted
No update 2+ yrs
FENN-87 — Make detailed staff training records locally available to station supervisors
Recommendation: Detailed records of all training given to individual staff shall be available locally to station supervisors.
Unknown
43 — Church in Wales record-keeping policies
Recommendation: The Church in Wales should introduce record-keeping policies relating to safeguarding, complaints and whistleblowing. These should be implemented consistently across dioceses. The Church should develop policies and training on the information that must be recorded in files. The Church should …
Gov response: On 7 April 2021, the Church in Wales stated that its national online safeguarding case management and record-keeping system had launched, serving as a single searchable repository of all Church in Wales safeguarding and whistleblowing …
Accepted
Delivered
5 — Reform Church of England clergy discipline for safeguarding
Recommendation: The Church of England should make changes and improvements to the way in which it responds to safeguarding complaints (whether related to allegations of abuse, or a failure to comply with or respond to the Church's safeguarding policies and procedures) …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council endorsed the proposals of the Clergy Discipline Measure working group to replace Clergy Discipline …
Accepted
No update 2+ yrs
7 — Catholic complaints policy with escalation process
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a national policy for complaints about the way in which a safeguarding case is handled. The policy should deal with communication with complainants during the …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that a framework and template for complaints was ratified by the Bishops. The framework and template include the need for clear communication between the …
Accepted
Delivered
85 — Access to records for former child migrants
Recommendation: The Chair and Panel have recommended that all institutions which sent children abroad as part of the child migration programmes should ensure that they have robust systems in place for retaining and preserving any remaining records that may contain information …
Gov response: Between January and July 2020, Action for Children, Barnardo's, Catholic Church in England and Wales, Cornwall Council, Father Hudson's Care, Salvation Army UK, Sisters of Nazareth, The Children's Society and The Prince's Trust committed to …
Accepted
Delivered
FR-17 — Code of Practice on Records Access
Recommendation: The Inquiry recommends that the UK government directs the Information Commissioner's Office to introduce a code of practice on retention of and access to records known to relate to child sexual abuse. The retention period for records known to relate …
Gov response: We accept the importance of access to records. We will engage with the Information Commissioner’s Office on implementing this recommendation.
Accepted in Part
In progress
6a — Communicating complaint escalation
Recommendation: We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and the independent sector.
Gov response: Accepted. NHS complaints processes now more clearly signpost to Parliamentary and Health Service Ombudsman. Independent Healthcare Providers Network has agreed to ensure members inform patients about Independent Sector Complaints Adjudication Service (ISCAS). CQC monitors complaints …
Accepted
No update 2+ yrs
6b — Mandatory independent complaint resolution
Recommendation: We recommend that all private patients should have the right to mandatory independent resolution of their complaint.
Gov response: Accepted in principle. Government supports principle but further work needed on implementation mechanism. ISCAS membership has grown significantly since the inquiry. Government is considering whether legislative change is needed to make independent adjudication mandatory for …
Accepted in Part
No update 2+ yrs
IHRD-17 — Recording Changes in Accountability
Recommendation: Any change in clinical accountability should be recorded in the notes.
Gov response: Incorporated into clinical documentation standards.
Accepted
Delivered
IHRD-29 — Record Keeping Audit
Recommendation: Record keeping should be subject to rigorous, routine and regular audit.
Gov response: Record keeping audit programmes established across Trusts.
Accepted
Delivered
L10 — Complaint Handling Mechanism
Recommendation: The Board should require all those who subscribe to have an adequate and speedy complaint handling mechanism; it should encourage those who wish to complain to do so through that mechanism and should not receive complaints directly unless or until …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L11 — Power to Hear Complaints
Recommendation: The Board should have the power to hear and decide on complaints about breach of the standards code by those who subscribe. The Board should have the power (but not necessarily in all cases depending on the circumstances the duty) …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L12 — Complaint Decision Responsibility
Recommendation: Decisions on complaints should be the ultimate responsibility of the Board, advised by complaints handling officials to whom appropriate delegations may be made.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L13 — Complaints Committee Composition
Recommendation: Serving editors should not be members of any Committee advising the Board on complaints and any such Committee should have a composition broadly reflecting that of the main Board, with a majority of people who are independent of the press.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L14 — Free Complaints Process
Recommendation: It should continue to be the case that complainants are able to bring complaints free of charge.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L20 — Compliance Record Keeping
Recommendation: The Board should have both the power and a duty to ensure that all breaches of the standards code that it considers are recorded as such and that proper data is kept that records the extent to which complaints have …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
CLAR-3 — Remind agencies to keep detailed, accurate records, especially mortuary documentation
Recommendation: We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.
Unknown
F109 — Effective complaints handling
Recommendation: Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally …
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
F110 — Lowering barriers
Recommendation: Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential litigation to agree to a stay of proceedings pending the …
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
F111 — Lowering barriers
Recommendation: Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the …
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
F112 — Lowering barriers
Recommendation: Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as a formal complaint, whether or not the informant has indicated …
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
F113 — Complaints handling
Recommendation: The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.
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
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
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
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
F116 — Support for complainants
Recommendation: Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support.
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
F117 — Support for complainants
Recommendation: A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.
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
F118 — Learning and information from complaints
Recommendation: Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, …
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
F119 — Learning and information from complaints
Recommendation: Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.
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
F120 — Learning and information from complaints
Recommendation: Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board …
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
F121 — Learning and information from complaints
Recommendation: The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying 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
F133 — Role of commissioners in complaints
Recommendation: Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, while respecting the principle that it is the provider who …
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
F134 — Role of commissioners in provision of support for complainants
Recommendation: Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.
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
F151 — Complaints to MPs
Recommendation: MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.
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
F246 — Comparable quality accounts
Recommendation: Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form to enable comparisons to be made between organisations, to include a minimum of prescribed information about their compliance …
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
F247 — Accountability for quality accounts
Recommendation: Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators.
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
F248 — Accountability for quality accounts
Recommendation: Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability of all statements in the accounts.
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
F249 — Accountability for quality accounts
Recommendation: Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account to be true, or alternatively a statement of explanation as …
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
F250 — Accountability for quality accounts
Recommendation: It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of fact concerning an item of prescribed information which he/she does …
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
F251 — Regulatory oversight of quality accounts
Recommendation: The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. In the event of an organisation failing to take 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
F254 — Access for public and patient comments
Recommendation: While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be consistency across the country in methods of access, and for …
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
F255 — Using patient feedback
Recommendation: Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" as possible, even if later adjustments have to be made.
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
F259 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns of clinically related complaints.
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
F38 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local …
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
F39 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.
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
F40 — Use of information about compliance by regulator from: Complaints
Recommendation: It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.
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
1 — Admit problems and apologise to affected families
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
13 — Improve complaints handling
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
31 — Fundamental review of NHS complaints system
Recommendation: The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature …
Gov response: 72. We accept this recommendation in principle and recognise that there are still challenges to overcome if we are to see improvements in the way complaints are handled in the NHS. However, we do not …
Accepted
34 — CQC and PHSO memorandum of understanding
Recommendation: The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service …
Gov response: 90. We accept this recommendation. The Investigation found that the lack of co ordination between the Care Quality Commission and the Parliamentary and Health Service Ombudsman was a contributory factor to the ongoing inability of …
Accepted
WATE-(15) — Maintain log of children's home incidents at police station for social services
Recommendation: A log of all incidents, disturbances, reports, complaints and absconsions at a children's home should be kept at an appropriate nearby police station and made accessible, when required, to officers of the Social Services Department.
Unknown
WATE-(18) — Appoint senior officer to strategise serious staff misbehaviour complaints
Recommendation: When a complaint alleges serious misbehaviour by a member of staff, the Director of Social Services should appoint a senior officer to formulate an overall strategy for dealing with the complaint, including such matters as liaison with the police in …
Unknown
WATE-(3) — Require appointment of independent Children's Complaints Officer in every social services authority
Recommendation: Every social services authority should be required to appoint an appropriately qualified or experienced Children's Complaints Officer, who should not be the line manager of residential or other staff who may be the subject of children's complaints or complaints relating …
Unknown
WATE-(39) — Require fostering services to monitor, analyse, and report placement breakdowns periodically
Recommendation: Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director …
Unknown
WATE-(4) — Define specific duties for Children's Complaints Officers, prioritising child's best interests
Recommendation: Amongst the duties of the Children's Complaints Officer should be: (a) to act in the best interests of the child; (b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child; …
Unknown
WATE-(6) — Local authorities promote awareness of complaints procedures for looked after children
Recommendation: Every local authority should promote vigorously awareness by children and staff of its complaints procedures for looked after children and the importance of applying them conscientiously without any threat or fear of reprisals in any form.
Unknown
WATE-(7) — Ensure comprehensive and impartial complaints procedures for looked after children
Recommendation: Such complaints procedures should: (a) be neither too prescriptive nor too restrictive in categorising what constitutes a complaint; (b) encompass a wide variety of channels through which complaints by or relating to looked after children may be made or referred …
Unknown
RHI-26 — Meeting Records
Recommendation: Notes of significant meetings between officials and ministers, particularly those affecting decision-making and spending, must be taken and retained. The responsibility for ensuring this is done should be clearly identified and compliance should be ensured in practice.
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
RHI-27 — Private Office Record Keeping
Recommendation: Ministers' responses to submissions should be formally and timeously recorded and disseminated to officials by the Minister's Private Office. That responsibility should not be left to policy teams. One clear corollary is the need for a better system to carry …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
RHI-28 — Record Keeping Culture and Audit
Recommendation: The culture and practice of record keeping and access to records within the Northern Ireland Civil Service needs to change so that staff responsible for a given area of work have easy access to the analysis and decisions underpinning the …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
No update 2+ yrs
SHI-9 — Documentation of technical adviser advice
Recommendation: I accordingly recommend that a similar procedure should be considered when technical advisers (particularly engineers) are providing specific technical advice in relation to a project such as the RHCYP and DCN. There should be a clear record of the advice …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
MACP-27 — Formally record and report all family requests and complaints to superior officers.
Recommendation: That good practice shall provide that any request made by the family of a victim which is not acceded to, and any complaint by any member of the family, shall be formally recorded by the SIO and shall be reported …
Unknown
R32 — Staffing concerns escalation
Recommendation: Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.
Gov response: Section 4.1 of the Scottish Government's response highlights that the NMC code requires registered nurses and midwives to escalate concerns regarding patient safety or the level of care. To support this, a national whistleblowing policy, …
Accepted
R33 — Nursing complaint investigation
Recommendation: Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an independent senior member of Nursing Management.
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's finding of 'poor complaint management by nursing teams,' which forms the substance of recommendation 33. While the response generally accepts recommendations relating to nursing care, …
Accepted
LAMI-29 — Implement system for directors to monitor children's social services duty team data
Recommendation: Directors of social services must devise and implement a system which provides them with the following information about the work of the duty teams for which they are responsible: • number of children referred to the teams; • number of …
Unknown
LAMI-69 — Record all discussions, including phone calls, in child deliberate harm case notes.
Recommendation: When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which …
Unknown
PFD Reports (64)
Janet Tripp
Concerns: Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Pending
Linda Books
Concerns: The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about Serious Incident Report procedures.
Pending
Ronald Nelson
Concerns: Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Overdue
Stephen Lawrence
Concerns: A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.
Responded
Melissa Mathieson
Concerns: The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.
Responded
Ann Caldicott
Concerns: Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.
Responded
Nicholas Gray
Concerns: The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential investigation requirements.
Responded
Khadija Kerri
Concerns: The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and treating a patient's fractures.
Responded
Alice Clark
Concerns: Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
Responded
Allan Hamilton
Concerns: A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.
Responded
Elise Walsh
Concerns: A significant patient complaint form, containing a "note of intent," was not read or included in investigations, and the family was unaware of it, indicating critical failures in handling patient information.
Responded
Alan Fallows
Concerns: Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents effectively.
Responded
Anoush Summers
Concerns: A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training on alarm testing, and there was no clear system for fault reporting between agencies.
Responded
Jada Monoja
Concerns: An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Responded
Mohammed Azizi
Concerns: Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Responded
Keith Smith
Concerns: The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the death.
Responded
Nesta Jones
Concerns: Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed to conduct a full, timely investigation into the death.
Responded
Thomas Loxton
Concerns: Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical safety recommendations remain outstanding or delayed.
Responded
Thomas Ithell
Concerns: The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.
Responded
Jennifer Campbell
Concerns: A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.
Responded
Ronald Harris
Concerns: Incomplete triage documentation, failure to contact the patient, and a lack of awareness by the triage doctor regarding appointment waiting times and call details, resulted in no revised mental health triage protocol after the incident.
Responded
Stephen Weatherley
Concerns: Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Responded
Emily Corfield
Concerns: An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.
Responded
Sam Taylor
Concerns: Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and highlighted a lack of effective systems for identifying process failures.
Responded
Alexander Blewitt
Concerns: Critical failures included unreliable recording of IV fluids, missed communication during triage, and contradictory medical notes. The incident investigation was inadequate, failing to address systemic issues or ensure timely corrective actions eight months post-death.
Responded
Bency Joseph
Concerns: There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also deficient, excluding key stakeholders.
Responded
Colin Gumm
Concerns: Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.
Responded
Peter Lawrence
Concerns: An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially endangering future patients.
Overdue
David Nash
Concerns: The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.
Responded
Peter Ross
Concerns: A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures among clinical staff and poor record-keeping led to serious patient harm.
Responded
Sameena Javed
Concerns: The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.
Overdue
Margaret Greenacre
Concerns: The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.
Responded
Monica McCormick
Concerns: A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have prolonged life.
Responded
Sidney Baker
Concerns: Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.
Responded
Tina Tait
Concerns: Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
Overdue
Peter Carroll
Concerns: A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was a lack of leading physician sign-off on reports.
Responded
John Duckenfield
Concerns: Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.
Responded
Agnes Lambert
Concerns: Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Responded
Paliben Dullabh
Concerns: The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI scans.
Pending
Kathleen Smith
Concerns: The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a single, departed manager, with no audit or review since, despite missing documentation.
Responded
Janet Williams
Concerns: The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.
Overdue
Sean Plumstead
Concerns: Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Responded
David Evans
Concerns: An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.
Overdue
Thomas Whitfield
Concerns: Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.
Overdue
Grant Richards
Concerns: The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.
Overdue
Marian Dale
Concerns: The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after death.
Overdue
Matthew Roberts
Concerns: There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.
Responded
Margaret Pegnall
Concerns: A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.
Pending
William Tolen
Concerns: Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.
Responded
Joyce Hartford
Concerns: Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.
Responded
Tom Sawyer and Danny Winters
Concerns: Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack of secure digital recording for encrypted radio signals in combat scenarios.
Pending
John Dack
Concerns: Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted in serious consequences.
Responded
Kimberley Lindfield
Concerns: Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.
Responded
Philip Smith
Concerns: Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.
Overdue
Samia Shara
Concerns: There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.
Overdue
Connor Smith
Concerns: An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality that could hinder learning from incidents.
Overdue
Seweryn Glowinski
Concerns: Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Overdue
Thomas Dixon
Concerns: Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify these ongoing administrative issues affecting patient care.
Overdue
Stanley Bere
Concerns: Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries not being promptly identified or followed up by staff.
Overdue
Marion Turner
Concerns: A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to a significant and dangerous delay in response.
Overdue
Clive Clinton
Concerns: A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
Overdue
Pauline Meredith
Concerns: Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Response: The surgery is undertaking an audit of all patients on opioid medication, developing a new protocol for prescribing opioids for chronic pain, and will train staff on this protocol. They …
Overdue
Jonathan Thorpe
Concerns: A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
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: The General Medical Council acknowledges the concerns but states no action is proposed as their previous investigation was closed due to the five-year rule and they have received no further …
Responded