Complaint record keeping failures
Failures in maintaining accurate and procedural records for managing complaints in residential care homes.
10,594 items
17 sources
21 inquiries
Source spread
Where this theme appears
Complaint record keeping failures has been flagged across 17 independent accountability sources:
79 inquiry recs
65 PFD reports
238 committee recs
89 CQC actions
10 HMICFRS recs
18 ICIBI recs
33 PPO recs
25 IOPC recs
16 NAO recs
8 VC recs
7 IMB reports
504 IMB recs
13 Article 2 learning points
13 detention investigation recs
632 PHSO decisions
8842 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 (79) — showing 50 strongest matches
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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-(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-(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
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
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
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
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
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
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
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
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
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
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
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
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
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
SP60 — School safeguarding recording systems
Recommendation: The Department for Education should ensure (either by direct guidance or through Ofsted) that all schools are required to record safeguarding information in a system that is fit for purpose.
Response Pending
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-(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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
PFD Reports (65) — showing 50 strongest matches
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
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
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 (Browning Street Surgery): The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health …
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
Marion Turner
Concerns: The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was not read until after her death.
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.
Response (Older Peoples Services): Older Peoples Services has tightened reporting systems for falls and accidents, introduced a more secure system of archiving, and now ensures they have copies of district nurses' records for residents. …
Overdue
Thomas Dixon
Concerns: The report identifies failures to schedule timely appointments and a missing referral form. The coroner expressed concern that these issues may impact other patients, particularly in screening and follow-up, and suggested a review of the action plan addressing these concerns.
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
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.
Response (Prisons Probation Ombudsman): The PPO acknowledges a minor factual inaccuracy in their report, but argues it had no material bearing on the circumstances of the death and that they cannot take further action …
Response (HM Prison and Probation Service): HMP Altcourse has issued a notice to all senior managers who chair Segregation Review Boards, advising them that the documentation for completion at the meeting must not have names entered …
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
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
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.
Response (Manchester Mental Health NHS): Manchester Mental Health and Social Care Trust (MMHSCT) has agreed to provide UHSM with advice in respect of their development of a self-harm policy and guidance. Regular liaison meetings will …
Response (Department of Health): The Department of Health acknowledges the concerns raised and outlines several existing initiatives related to mental health and self-harm prevention, including national indicators, research funding, and the Mental Health Action …
Responded
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.
Response (Barts Health NHS Trust): Barts Health NHS Trust investigated the incident and has reminded staff of the importance of accurately changing patient details and the consequences of not doing so. They note that the …
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.
Response (Ministry of Defence): The MOD will investigate the inclusion of automated secure voice logs in the next generation tactical command system, with a decision expected by 2018. The Army Chief Information Officer will …
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.
Response (Pennine Acute Hositals NHS Trust): Pennine Acute Hospitals NHS Trust has been undertaking a review of current documentation and monthly audits of nursing metrics on Ward T7, and implemented measures trust-wide. They are also reviewing …
Responded
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.
Response (William Tolen): Staff have received further supervision and training in relation to documentation, and instructions have been added to staff diaries. Staff have been requested that requests are stated clearly and that …
Responded
Edna Cleaton
Concerns: The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
Overdue
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.
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.
Response (Sussex Partnership NHS Trust): Sussex Partnership NHS Foundation Trust supplemented Information Governance training for EIP staff with posters on fax receipt. The EIP service developed a transition proforma, a best-practice tool for use by …
Responded
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
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
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
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
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.
Response (HM Prison Probation Services): HMP Winchester has taken on a temporary staff member to transcribe telephone calls, implemented a new protocol for information gathering, transcribed interview discs, and ordered a secure storage facility for …
Response (Carillion): Carillion has contacted HMPPS and proposed a formal instruction for staff to undergo SASH training, is ready to issue a notice to site managers to make staff available, and suggested …
Response (HM Prison Probation Services.2): The prison has issued notices to staff regarding emergency call bell response times and to prisoners about the misuse of call bells. The prison is also checking ECB response times …
Responded
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.
Response (Borough Care): Borough Care has introduced a weekly form for managers to report significant incidents to the Head of Care, discussed in weekly Care & Quality meetings, with Area Support follow-up.
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.
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.
Response (Camden and Islington NHS Trust): The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge …
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.
Response (Brancaster Care Home): The care home revised its policy on observations and record keeping, trained all registered nurses in January 2019, issued them with the new procedure, and implemented monthly audit checks on …
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.
Response (Manchester University NHS Trust): The Department of Histopathology has implemented measures to redirect cases outside a pathologist's area of expertise, list all confirmed cancer cases for discussion at multidisciplinary team meetings, and directly email …
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.
Response (Rosewood): Rosewood Healthcare has implemented an Accidents and Incidents file, follows a Triage system, and has online and face-to-face training for falls and manual handling. They also have a new training …
Response (CQC): The CQC conducted a comprehensive inspection of Barley Brook, and found that appropriate referrals were being made to dieticians and the falls team. They are highlighting possible breaches of the …
Response (Wigan Council): Wigan Council has taken action following a safeguarding enquiry, including developing a protection plan defining expectations for service delivery at Barley Brook. Staff will receive training in record keeping, dementia, …
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.
Response (Northern Care Alliance NHS Trust): The Northern Care Alliance has added cancers identified via treatment to the cancer tracking database. They are also reviewing management of leave by clinical staff, the process for clinical and …
Response (Northern Care Alliance NHS Trust): The Northern Care Alliance has added cancers identified via treatment to the cancer tracking database. They are also reviewing management of leave by clinical staff, the process for clinical and …
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.
Response (Alcyone Healthcare): The care home is under notification to close and transitioning to a new provider. The new management team is developing safe operation of the home including enhanced leadership, new compliance …
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.
Response (Barking, Havering and Redbridge University Hospitals NHS Trust): Barking, Havering and Redbridge University Hospitals NHS Trust has taken multiple actions, including completing SI recommendations within Radiology, providing formal radiology training, sending reminders to staff regarding C-spine injury, developing …
Response (Department of Health and Social Care): Barking, Havering & Redbridge NHS Trust presented the specific incident relating to Mr Ross at the Trust-wide Patient Safety Summit, delivered proposed teaching sessions for staff, made improvements to documentation, …
Responded
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.
Response (NHS England): NHS England will remind regional complaints teams to share final responses with providers, include a reference to the Report in the next National Learning Report, and remind teams to liaise …
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
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.
Response (Lincolnshire County Council): The council explains existing processes for safeguarding and quality monitoring of care providers, stating they are satisfied that appropriate assurances are undertaken to see whether action does need to be …
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.
Response (Essex Partnership University NHS Foundation Trust): The Trust has completed a Clinical Review into the death, shared learning with the Chair of the Clinical Review Group, and responded to the family's concerns raised after the inquest. …
Responded
Alexander Blewitt
Concerns: The coroner notes concerns about the lack of reliable recording of intravenous fluids in the emergency department, missed points during triage, and a failure to record a major presenting symptom by the treating doctor; the Incident Investigation Report was also found to be of a poor standard.
Response (Milton Keynes University Hospitals): The hospital is implementing mandatory training for ED staff on referral note review, accurate medication documentation, and sepsis protocols. The Chief Nurse and Medical Director will write to all registered …
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.
Response (Herefordshire Council): Herefordshire Council has made changes to the structure, processes, and practice within the service, including robust processes and proactive work with partners. A system for identifying process failure is now …
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.
Response (Adferiad): Adferiad is seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, …
Response (Betsi Cadwaladr University Health Board): The Health Board has re-issued communication detailing the referral process to liaison services and will share it with clinical teams across the Health Board to ensure there is clarity and …
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.
Response (HM Inspectorate of Prisons): HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform …
Response (HM Inspectorate of Prisons): HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform …
Response (Serco 1): Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings …
Response (HM Prison and Probation Service): HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators …
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.
Response (Hereford Medical Group): Hereford Medical Group implemented a new process allowing clinicians to listen to phone calls when online forms are unavailable, changed the staff newsletter to include the most up to date …
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.
Response (Betsi Cadwaladr University Health Board): The Health Board implemented a new standing operating procedure for endoscopy referrals in November 2023 and scans all paper referrals into the endoscopy email inbox. Referrals are also recorded onto …
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.
Response (Betso Cadwaladr University Health Board): Betsi Cadwaladr University Health Board has raised an incident report and initiated a full investigation into a patient lost to follow-up; it also plans to survey staff experiences with the …
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.
Response (Dudley Integrated Health and Care NHS Trust): Dudley Integrated Health and Care NHS Trust has implemented a more enhanced process for notifying internal and external stakeholders when a patient has died. They are also ensuring these changes …
Response (Black Country Healthcare): Black Country Healthcare has completed a review of the action plan presented at inquest, providing further insight into the completion of all areas of learning identified as a result of …
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.
Response (Betsi Cadwaladr University Health Board): The Health Board is issuing a Safety Alert by the end of April 2024 to share learning from the case and improve the process of listening to professional views and …
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.
Response (Church Elm Lane Medical Practice): The practice outlines actions taken and planned, including immediate actions, short-term improvements, formal reviews, individual feedback, staff training on message escalation, care navigation and escalation training, GP observation of reception …
Responded
Committee Recommendations (238) — showing 50 strongest matches
#5 —
Recommendation: The Department lacks good enough data to understand the nature and extent of problems renters face. The Department lacks sufficient data on the challenges facing landlords, tenants, and local authorities within the sector. For example, it lacks robust data on …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Spring 2023 5.2 The department utilises a range of data from various sources to inform policy decisions and ensure effective private rented sector (PRS) regulation, …
Not Addressed
#16 —
Recommendation: The Department received 6,521 complaints about child maintenance (around six for every 1,000 customers) in the year to 30 September 2021. This was considerably down from pre-pandemic levels in line with a general fall in complaints to the Department during …
Gov response: 5a. PAC recommendation: The Department should use its digital transformation to develop performance indicators that enable it to fully understand why customer satisfaction is so low, and target improvement where data suggests there may be …
Accepted
#29 —
Recommendation: We recommend that the Government legislate through the Social Housing (Regulation) Bill to place a legal requirement on social housing providers to self-assess against the Housing Ombudsman’s complaint handling code and to report to the ombudsman when they have done …
Gov response: We believe the Complaint Handling Code has had a significant and positive impact on social landlords’ approach to complaint handling. There has been a high level of engagement with the Code with more than 4,000 …
Accepted
#27 —
Recommendation: The introduction of the Housing Ombudsman’s complaint handling code and complaint handling failure orders must drive improvement and consistency in the way providers respond to complaints. We are pleased therefore that the Government is legislating through the Social Housing (Regulation) …
Gov response: 27. In summary, we look forward to continuing to work with tenants and other stakeholders as we develop a new proactive consumer regulation regime.
Under Consideration
#21 — Analyse complaint data to identify systemic issues and report quarterly on service improvements.
Recommendation: Users of such a service must receive assurance that information about complaints and failures is being aggregated and used proactively to improve systems and services, not just to effect redress to the individual. In order to achieve this, the Department …
Gov response: The inquiry highlighted the complexity of complaints processes across transport modes and operators, and the Department has already been working with disabled people’s representative groups to improve the information available to people about their rights …
Not Addressed
#26 — Reducing Energy Ombudsman escalation time risks increased caseloads, slower resolutions, and higher consumer bills.
Recommendation: We have reservations about the Government’s proposal to reduce the time before a case can be escalated to the Energy Ombudsman from eight to four weeks. This would likely inflate the volume of cases referred to the Ombudsman, which might …
Gov response: Too many Energy Ombudsman (EO) rulings are not implemented on time and in full, and all consumers should be confident that, where the EO has made a ruling in their favour, it will be acted …
Not Addressed
#15 — Clarify commission complaint procedures for maladministration and Police Ombudsman's investigative powers over state actors.
Recommendation: The Joint Framework and Troubles Bill partially fill the gap in commission accountability left by the Legacy Act. It is still unclear, however, what procedure there is to complain about maladministration or service failure by the commission. The Government must …
Gov response: The ICRIR has set out its Complaints Handling Policy publicly. The exercise of police powers by ICRIR officers is subject to separate, external oversight arrangements, in line with standard practice for policing powers. Any complaint …
Partially Accepted
#19 — Review support for NHS Muslim staff to ensure protection and effective reporting of abuse.
Recommendation: In light of increases in anti-Muslim hate in society, the NHS should review the support available to its Muslim staff and ensure that staff feel protected and able to report abusive and discriminatory behaviours in the knowledge that the necessary …
Gov response: 56. NHS staff should feel safe at work in an environment free of racism and discrimination. Every NHS organisation has a duty to protect staff from racism, sexism and religious hatred and will have their …
No Published Response
#9 — Mandate regional mayors to lead awareness and trust-building for anti-Muslim hate reporting services.
Recommendation: Given reforms to the provision of local services, including the proposed abolition of police and crime commissioners, we recommend regional mayors take a lead role in working with community organisations to raise awareness of the reporting service, to build trust …
Gov response: 34. We recognise the valuable role that Mayors can play in working with local partners to address issues that affect their communities, including those highlighted in the Report. Under the English Devolution and Community Empowerment …
No Published Response
#8 — Third-party reporting mechanisms for anti-Muslim hatred are vital and require inclusivity.
Recommendation: We welcome the Government’s introduction of a new fund to support a third-party reporting mechanism for victims of anti-Muslim hatred. Such mechanisms can play a vital role in enabling individuals to report hate crimes, particularly in cases where mistrust of …
No Published Response
#5 — Significant underreporting of intersectional hate incidents against Muslim women hinders effective intervention.
Recommendation: The significant underreporting of hate incidents against Muslim women is a concern, and a barrier to it being tackled. Reasons for underreporting are various but include a lack of awareness of and confidence in the process. It is essential that …
Gov response: 27. The Committee asked that Government ensure police officers are appropriately trained to effectively deal with hate crimes targeted at Muslim women. The Government recognises the importance of ensuring officers are appropriately trained to recognise, …
No Published Response
#12 — Confusing and poorly handled patient complaints system hinders early resolution efforts.
Recommendation: The 2025 Dash review of patient safety found that the current system for raising complaints and concerns is confusing, with issues often poorly handled and patients subject to delays and poor-quality responses. Research commissioned by NHS Resolution found that improving …
Gov response: 2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2b. PAC recommendation: The Department must review the NHS complaints system and improve the number of cases …
Accepted
#2 — Establish a national framework for patient safety with clear targets and improved complaints system.
Recommendation: The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing …
Gov response: The government disagrees with the Committee’s recommendation The wider question around the health economics of patient safety will be explored as part of the forthcoming update to the NHS Patient Safety Strategy by working with …
Accepted
#26 — AIRE service lacks follow-up mechanisms, creating accountability gap for complaints
Recommendation: Migrant Help is not contracted to follow up on or monitor issues and does not have sight of the response from providers and the Home Office. This creates a significant gap in accountability. We recognise the value of enabling asylum …
Gov response: Delivering the AIRE service solely at a local level would be challenging due to its scale, regulatory requirements, and need for consistent 24/7 support. The current model supports over 106,000 asylum seekers and manages high …
Not Addressed
#2 —
Recommendation: In May 2020, the PHSO reported to the Committee that it had experienced an increase of 13 per cent in demand compared to the previous financial year. Due to the introduction of a new digital casework management system, comparisons between …
Gov response: PHSO is open and transparent about the performance of the service we provide. The information we provided to the Committee in May 2020 was and is correct. Accordingly, the Ombudsman wrote to the Committee on …
Under Consideration
#1 —
Recommendation: The information provided in the PHSO’s annual report on the outcome of enquiries and complaints should be made more transparent. The grouping of cases that “are not ready to be taken forward” and “should not be taken forward” should be …
Gov response: The Committee has a crucial role in holding PHSO’s independent service to account. As an Officer of the House, the Ombudsman is fully committed to being open and transparent about the performance of the service …
Under Consideration
#22 —
Recommendation: The Local Government and Social Care Ombudsman expressed concerns about its oversight of combined authorities, pointing to uncertainties over its jurisdiction and a loss of oversight when unitarisation occurred. We agree that proper complaints procedures should be in place in …
Gov response: The Local Government and Social Care Ombudsman have raised their concerns with the Department regarding their oversight of combined authorities and some town and parish councils. The Local Government and Social Care Ombudsman’s Triennial Review …
Under Consideration
#7 —
Recommendation: The Committee recommends that the PHSO learns from and implements best practice at the Local Government and Social Care Ombudsman by publishing feedback scores about its service, split between those complainants who were happy with the result of their case …
Gov response: We have recently completed a six-month pilot, which required staff to come into the office a minimum of two days per week pro rata, to develop an evidence base for a longer-term hybrid model of …
Under Consideration
#6 —
Recommendation: The PHSO have improved the data output about their own performance in recent years, which the Committee applauds. Nevertheless, the Committee is of the view that even more open and transparent access to feedback data will enable external stakeholders to …
Gov response: As we start implementing PHSO’s new People Strategy, the focus is to strive for an inclusive colleague community. We have been integrating best practice into our recent recruitment drive. During 2021–22, 27.7% of appointed candidates …
Under Consideration
#3 —
Recommendation: The PHSO should also consider developing and reporting against timeliness targets for each grade of “severity of injustice” to better monitor the impact of the backlog on higher category cases in Levels 3 to 6.
Gov response: The Service Charter provides a valuable source of feedback about people’s experiences of PHSO’s service. We are committed to improving people’s experience of PHSO’s service and, in turn, improving these three low-performing scores. However, as …
Accepted
#2 —
Recommendation: The PHSO should more clearly notify visitors to its website which cases are not being considered under this new policy and further update the Committee on the review outlined to the Committee during the oral evidence session. The PHSO should …
Gov response: Our Severity of Injustice scale was developed to determine an appropriate level of financial remedy after the conclusion of the investigation, in the small number of detailed investigation cases where a financial remedy is one …
Partially Accepted
#1 —
Recommendation: The Committee notes the actions taken by the Parliamentary and Health Service Ombudsman to ensure continuing services to the public in difficult and unprecedented circumstances throughout the pandemic. However, the Committee notes the substantial backlog which has developed as a …
Gov response: Since April 2021, we have focussed PHSO’s resources on the more serious health complaints, in line with an approach already widely used across the Ombudsman sector. In practice, we have continued to examine all complaints …
Accepted
#17 —
Recommendation: Despite child maintenance having the highest rate of complaints within the Department, the Department upholds a lower proportion of complaints relating to child 21 Qq 124–125; C&AG’s Report, paras 5, 1.14, 3.10 22 C&AG’s Report, para 3.11 and 3.12 23 …
Gov response: 5b. PAC recommendation: The Department should also, within one year, review Child Maintenance cases where the Independent Case Examiner has upheld a complaint and report to us its analysis of the key themes and lessons …
Not Accepted
#5 —
Recommendation: The Department is too willing to blame low levels of customer satisfaction on CMS customers being difficult to please, despite its own systemic customer service failings. It is disheartening that customer satisfaction is no better now than it was under …
Gov response: The government disagrees with the Committee’s recommendation. The department’s Customer Experience Directorate actively invests in reviewing cases upheld by the Independent Case Examiner (ICE) to identify and implement service improvements. The department will continue to …
Not Accepted
#36 —
Recommendation: We encourage all social housing providers and the Housing Ombudsman to adopt a co-ordinated strategy to increase awareness among tenants of the ombudsman. As part of that, providers should routinely send letters and leaflets specifically about how they can complain …
Gov response: We agree with the Committee that improved awareness of, and access to, the complaints procedure is essential. We believe there is a higher-than-average awareness of the Housing Ombudsman compared to other Ombudsman schemes, with research …
Partially Accepted
#28 —
Recommendation: If they have not already done so, all providers must immediately review and where necessary improve their complaint handling processes. As part of this, all providers that have not already self-assessed against the ombudsman’s complaint handling code should immediately do …
Gov response: We believe the Complaint Handling Code has had a significant and positive impact on social landlords’ approach to complaint handling. There has been a high level of engagement with the Code with more than 4,000 …
Not Addressed
#26 —
Recommendation: The primary responsibility for resolving disputes between tenants and providers lies with the providers themselves, and yet too often their complaint handling processes are inefficient and obstructive. It is understandable if tenants sometimes conclude they have been specifically designed to …
Gov response: 27. In summary, we look forward to continuing to work with tenants and other stakeholders as we develop a new proactive consumer regulation regime.
Under Consideration
#9 —
Recommendation: In addition to the wider efforts to improve basic documentation, the Department told us that it had introduced measures such as spot checks by the principal private secretary to reinforce the importance of proper record-keeping in private offices. The Department …
Gov response: 1: PAC conclusion: Woefully inadequate record-keeping by the Department makes it impossible to have confidence that all its contracts with Randox were awarded properly. 1: PAC recommendation: The Department should write to us within two …
Accepted
#17 —
Recommendation: Although the Electoral Commission has an overall strong record in relation to monitoring, investigations and enforcement, we were concerned by the individual cases of extremely lengthy investigations and poor communication raised throughout this inquiry. The Electoral Commission has said it …
Gov response: The Government agrees with the Committee’s view that it is important to resolve investigations within a reasonable time period. Currently, prosecutors have six months from receiving sufficient evidence to bring such proceedings in relation to …
Not Addressed
#11 —
Recommendation: Many customers went to their MPs for help: complaints received via MPs increased from 2,600 per year in the two years before the pandemic, to 26,800 in 2021–22. The DVLA explained to us that people were coming to MPs because …
Gov response: 2. PAC conclusion: The DVLA’s communication during the pandemic was ineffective, leaving many customers feeling as if their applications were making no progress. 2b. PAC recommendation: The DVLA should also improve how it communicates this …
Accepted
#29 —
Recommendation: The Committee is encouraged by five organisations that have volunteered to adopt the UK Central Government Complaint Standards. We urge the PHSO to continue to engage with Government Departments and public sector organisations to increase this figure, and to report …
Gov response: The Government is supportive of the complaint standards and is pleased that a number of departments, including the Cabinet Office, have come forward as early adopters. Assuming that the Standards are shown to be working …
Under Consideration
#23 —
Recommendation: It is unsatisfactory that data provided to this Committee has been subsequently revised. The PHSO should report back to the Committee on what steps it is taking to quality assure its data before it is published and used by the …
Gov response: PHSO conducts a thorough review of all performance data on an annual basis. Data provided to the Committee is quality assured to the highest standard. We contracted a third-party provider to conduct the 2021 Staff …
Accepted
#10 —
Recommendation: The Committee is concerned by the fact that the PHSO has not met any of its targets for the overall section Service Charter scores in the 2021–22 financial year. The Committee had previously understood that the scores were expected to …
Gov response: The increase in staff turnover in 2021–22 was in-line with national trends following the pandemic. Turnover has now stabilised. As outlined in the Business Plan, we continue to prioritise developing PHSO’s people to ensure that …
Under Consideration
#6 —
Recommendation: We are concerned by the number of Level 1 and 2 cases that are not being considered by the PHSO due to the approach of prioritising health complaints using the severity of injustice scale. We recommend that the PHSO sets …
Gov response: PHSO considers all the complaints we receive. For complaints about the NHS where the claimed impact on the complainant is less serious, for example a cancelled medical appointment that was frustrating but had no clinical …
Accepted
#11 —
Recommendation: Teleperformance, the contractor responsible for HMPO’s customer support telephone line, failed to meet its service level agreement of answering 80% of calls within 30 seconds from March 2022 to July 2022. In May, it only managed to answer 14% of …
Gov response: 4.3 For the work of Teleperformance and Sopra Steria, HM Passport Office has worked closely with them to help ensure that they meet the required service level throughout 2023. 4.6 While Teleperformance did not meet …
Accepted
#15 —
Recommendation: We deplore the poor historical state of record keeping by the Ministry of Justice, Post Office Ltd, the Crown Prosecution Service and Royal Mail Group. Action must be taken to mitigate the risk that individuals eligible to have their convictions …
Response Pending
#9 —
Recommendation: The Committee recommends that the PHSO should publish a target for responding to correspondence, and should track its performance against that standard and report to the Committee each year. (Paragraph 31) Value for Money
Gov response: The Committee has a crucial role in holding PHSO’s independent service to account. As an Officer of the House, the Ombudsman is fully committed to being open and transparent about the performance of the service …
Under Consideration
#8 —
Recommendation: It is necessary for complaints to the PHSO to be time-limited, as there needs to be some level of certainty about when matters that could potentially be complained about can no longer be taken forward. However, the Committee’s view is …
Gov response: The Health Service Commissioner Act and Parliamentary Commissioner Act both set a legal time limit of 12 months from the date an individual became aware of a failing for the Ombudsman to investigate. They also …
Under Consideration
#7 —
Recommendation: The PHSO should report regularly in its annual report the number of cases in the queue for allocation to a caseworker and the average amount of time it took for cases to be allocated to a caseworker. This will be …
Gov response: The Committee has a crucial role in holding PHSO’s independent service to account. As an Officer of the House, the Ombudsman is fully committed to being open and transparent about the performance of the service …
Under Consideration
#6 —
Recommendation: The PHSO should provide a breakdown of how long health cases that are over one year old have been open for. This information should also be produced next to the general information the PHSO provides on the amount of time …
Gov response: The Committee has a crucial role in holding PHSO’s independent service to account. As an Officer of the House, the Ombudsman is fully committed to being open and transparent about the performance of the service …
Under Consideration
#5 —
Recommendation: The PHSO should report in its annual report and accounts the number of new enquiries and complaints that have been received in that financial year. This number is separate from the number of enquiries and complaints that the PHSO has …
Gov response: The Committee has a crucial role in holding PHSO’s independent service to account. As an Officer of the House, the Ombudsman is fully committed to being open and transparent about the performance of the service …
Under Consideration
#4 —
Recommendation: The Committee appreciates that there is a risk that complainants could be overwhelmed with information if all the evidence the PHSO has collected is shared with them, but it remains the case that complainants need to be assured that all …
Gov response: PHSO recognises the importance of being transparent about the material evidence (the evidence which we have taken into consideration in making a decision on a complaint). We set out in each final investigation decision report …
Under Consideration
#13 —
Recommendation: The pandemic has again highlighted the role of high-quality data in enabling effective service delivery, monitoring and improvement. For example, due to missing or inaccurate telephone numbers within NHS patient records, the shielding programme was unable to follow-up letters to …
Gov response: 2: PAC conclusion: Government’s ability to make well-informed decisions and address issues as they arise during the pandemic has been hampered by slow progress in addressing longstanding issues with data and legacy IT. 2a: PAC …
Not Addressed
#12 —
Recommendation: We have repeatedly highlighted longstanding issues with the quality of data held by government and with its ability to use data effectively to support policy interventions. In our 2019 report Challenges in using data across government, we noted the lack …
Gov response: 2: PAC conclusion: Government’s ability to make well-informed decisions and address issues as they arise during the pandemic has been hampered by slow progress in addressing longstanding issues with data and legacy IT. 2a: PAC …
Not Addressed
#23 —
Recommendation: The absence of records held by the Post Office Ltd. (POL) and other relevant organisations, such as HMRC, DWP and the Royal Mail Group, along with an absence of local suspense accounts for individual POL branches, raises serious questions as …
Gov response: The Government accepts the Committee’s recommendation.
Not Addressed
#5 —
Recommendation: The PHSO should set out how it plans to take to address the three-long term, low performing scores relating to how evidence is gathered, how decisions are reached and how decisions are made in a timely final decision.
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 …
Partially Accepted
#13 —
Recommendation: The FCDO failed to take the basic administrative step of recording its decisions. It is fundamental to any bureaucracy to know precisely what decisions have been made, by whom, with what authority, and when. This would be a serious failure …
Under Consideration
#34 —
Recommendation: The Government must commit to ensuring social housing tenants get the same levels of compensation it has said tenants in the PRS will be entitled to under its proposals for a new ombudsman. We recommend it does this by amending …
Gov response: In resolving a dispute, it is an Ombudsman’s role to put the complainant back in the position they would have been in had the service failure not occurred. We therefore firmly believe that non-financial remedies, …
Not Addressed
#33 —
Recommendation: We welcome the ombudsman’s decision to increase the levels of compensation for the most serious service failings, but even these are inadequate. If the Government thinks tenants in the private rented sector (PRS) should be entitled to compensation of up …
Gov response: In resolving a dispute, it is an Ombudsman’s role to put the complainant back in the position they would have been in had the service failure not occurred. We therefore firmly believe that non-financial remedies, …
Not Addressed
#32 —
Recommendation: The Housing Ombudsman is supposed to award compensation to cover financial loss and avoidable inconvenience, distress and detriment. We do not think, however, that the levels of compensation being awarded come anywhere close to reflecting any of these things. We …
Gov response: In resolving a dispute, it is an Ombudsman’s role to put the complainant back in the position they would have been in had the service failure not occurred. We therefore firmly believe that non-financial remedies, …
Partially Accepted
CQC Inspection Actions (89) — showing 50 strongest matches
Chy Byghan Residential Home
The provider must ensure people are provided with an effective and accessible complaint system.
Must Do
M N Pulse Solutions
improvement was needed to the records maintained such as to include dates and full detail about the incident and investigation.
Must Do
Kingfishers Nursing Home
The registered person failed to establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and others in relation to the carrying on of the regulated activity.
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure complaints are investigated appropriately and dealt with effectively, with proper records maintained.
Must Do
Figtree Care Services Ltd
The provider and registered manager failed to ensure accurate records were kept.
Must Do
Winterton House
The registered person did not operate an effective system for identifying, receiving, recording, handling or responding to complaints.
Must Do
Park Grange Care Home
There was not an effective system in place to ensure concerns and complaints were recorded and responded to appropriately.
Must Do
Kingsley Nursing Home
The registered manager and provider failed to: 2. have an effective system to receive, record, investigate or respond to complaints. 16 (2)
Must Do
Kingsley Nursing Home
The registered manager and provider failed to: 1. investigate or take necessary action in response to complaints. 16 (1)
Must Do
Chatting Independently Limited - Rectory Drive
People who use the service could not assured that any complaints would be acted on investigated and resolved to their satisfaction.
Must Do
Barton Park Nursing Home
Complaints were not being recorded or responded to in line with the registered providers complaints policy.
Must Do
B&H Care Ltd
The provider must ensure people's complaints and concerns are managed effectively to promote their health, safety and wellbeing, including having a system for independent investigation of complaints and maintaining records of complaints.
Must Do
Ashmore House
The provider must establish and operate an accessible system for identifying, receiving, recording, handling and responding to complaints.
Must Do
Ashbourne House - Torquay
The provider did not effectively record, handle and respond to complaints.
Must Do
Cygnet Bury Hudson
The provider must ensure that any complaints or concerns raised by patients, their families or carers, are logged, acknowledged, investigated, complainants are informed of the outcome in line with provider policy and lessons learned from investigating complaints are implemented and …
Must Do
Valewood House Nursing Home
We recommend that the complaints procedure is made more readily available to people and visitors.
Should Do
Trent Lodge Residential Care Home
We recommend that the service seek advice and guidance from a reputable source, about the management of and learning from complaints.
Should Do
Reside at Southwood
We recommend the provider ensures a full audit trail is followed in accordance with the provider's complaint policy.
Should Do
Haisthorpe House
The provider must ensure people who used services are protected from the impact of unsafe care and treatment by having an effective complaints process.
Must Do
The Long Brook Residential Home
We recommend the provider reviews the effectiveness of the current complaints systems.
Should Do
Multicare Services - Maylands Building
We recommend the provider ensures they investigate complaints thoroughly.
Should Do
Lady Ida Lodge
The provider was not operating an effective system for identifying, receiving, recording, handling and responding to complaints.
Must Do
Homelea Residential Care Home
Complaints investigations had not been documented to show actions had been taken.
Must Do
Dr Jude's Practice - Riverside & Picton
Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or its investigation.
Must Do
Darenth Grange Residential Home
The provider should ensure the complaints procedure is sufficiently detailed, explaining how and by when complaints will be resolved.
Should Do
Bousfield Surgery
Take action to acknowledge complaints in accordance with the providers complaint policy and document any learning from complaints.
Should Do
Valewood House Nursing Home
The complaints procedure should be made more readily available to people and visitors.
Should Do
The Homestead (Crowthorne) Limited
The registered person failed to operate an effective and accessible system for identifying, receiving, recording, handling and responding to complaints.
Must Do
The Elms
The provider should ensure that the person responsible for dealing with complaints acts in line with the policy.
Should Do
St Clare's Hospice
The provider must improve the complaints processes, so that patients understand how to make a compliant and staff investigate and learn following complaints.
Must Do
Salus Care Group - Braunstone
The provider failed to follow their complaints policy by investigating and taking the necessary and proportionate action to resolve any issues.
Must Do
Rosecroft Residential Care Home
The provider should ensure that complaints are appropriately recorded and maintained.
Should Do
Reside at Southwood
the provider ensures a full audit trail is followed in accordance with the provider's complaints policy.
Should Do
Etherley Lodge
The provider must ensure that record-keeping arrangements are in place which protect people, including maintaining accurate, fit-for-purpose, and securely stored personal and staff records, and ensuring staff supervision records are comprehensive and accessible.
Must Do
Elizabeth Street Surgery
Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
Must Do
Ashmore House
The provider must investigate and take proportionate action in response to any failure identified by a complaint.
Must Do
Archers Point Residential Home
The provider should ensure all complaints are logged and investigated effectively in line with the provider's complaints procedure.
Should Do
Darenth Grange Residential Home
The provider and registered manager seeks guidance from a reputable source to improve their responses to complaints received.
Should Do
Crown Street Surgery
Improve processes to record and share any learnings identified from complaints.
Should Do
Ash Court Care Centre - Camden
The registered person had not notified the Commission without delay of the events which occurred whilst the service was being provided in the carrying on of a regulated activity. Regulation 18 (Registration) (1) (2) (e)
Must Do
Melville House
The provider's complaints procedure information would benefit from reference to the local government ombudsman who would investigate complaints should the complainant be unhappy with the provider's investigation.
Should Do
Goldenley Care Home
Documentation did not always show what action was undertaken in response to identified shortfalls.
Should Do
Elsinor Residential Home
The provider had not established and operated sufficiently effective systems to assess, monitor and mitigate risks and to make sure complete and contemporaneous records were in place.
Must Do
Westhaven
The provider should update their complaints policy in relation to the organisation that should be contacted if complaints are not resolved by the provider.
Should Do
The Boltons
The registered person had failed to record and keep a copy of actions taken, as required of this regulation, when a notifiable safety incident occurred.
Must Do
St. David's Home
We recommend the provider consider current guidance on complaints handling and review their practices accordingly.
Should Do
St Marys Care Centre
The provider reviews their complaints policy and process.
Should Do
St Albans House
The provider should ensure the complaints policy is in a prominent place and in a format that is easy to read.
Should Do
Spindrift Care Home Limited
The provider was not effectively operating systems designed to assess, monitor and improve the quality of the service provided. The provider had not maintained an accurate, complete and up to date record of the care people received. The provider had …
Must Do
Roland Residential Care Homes - 27 Bush Hill
We recommend the provider reviews its processes for managing complaints to ensure records are kept in line with their procedure.
Should Do
HMICFRS Recommendations (10)
PEEL 2021-22 CoC Recommendations: Sussex Police
Cause of concern: The force is too often failing to record reports of violent crime, particularly behavioural crimes (harassment, stalking, controlling and coercive behaviour), rape crimes and incidents, domestic abuse and antisocial behaviour. Recommendation: Sussex Police should immediately take steps …
Recommendation
PEEL 2023-25 CoC Recommendations: Hertfordshire Constabulary
Cause of concern: The constabulary is failing to record reports of crime correctly Recommendation: With immediate effect the constabulary should review its crime-recording audit schedules and governance arrangements. It should give particular attention to crimes of rape, behavioural crimes, violent …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: Gloucestershire Constabulary is failing to record domestic abuse, behavioural crimes, and crimes linked to anti-social behaviour. This is significantly affecting the force’s crime recording standards. And it shows that victims of domestic abuse, behavioural crimes and anti-social …
Recommendation
FRS 2023-25 CoC Recommendations: Shropshire Fire and Rescue Service
Cause of concern: The service doesn’t have adequate processes, controls or internal governance arrangements in place to manage strategic risks, performance and improvement plans. Recommendation: The service should develop an action plan to make sure it has access to accurate …
Recommendation
PEEL 2023-25 CoC Recommendations: Hertfordshire Constabulary
Cause of concern: The constabulary is failing to record reports of crime correctly Recommendation: With immediate effect, the constabulary should address gaps in the systems and processes for identifying and recording all reports made by victims of crime. It should …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is failing to make sure it correctly records all reported crimes, particularly violent crime, including domestic abuse behavioural crimes such as harassment, stalking and coercive controlling behaviour. So these crimes are often not investigated and …
Recommendation
PEEL 2021-22 CoC Recommendations: Dyfed-Powys Police
Cause of concern: Dyfed-Powys Police is too often failing to record reports of violent crime, particularly domestic abuse and anti-social behaviour towards people. Recommendation: The force should immediately put in place arrangements to make sure that adequate supervision is applied …
Recommendation
PEEL 2021-22 CoC Recommendations: Devon and Cornwall Police
Cause of concern: Devon and Cornwall Police is too often failing to record reports of violent crime, particularly behavioural crimes (harassment, stalking, controlling and coercive behaviour), domestic abuse and anti-social behaviour. Recommendation: Within three months, Devon and Cornwall Police should …
Recommendation
PEEL 2021-22 CoC Recommendations: Devon and Cornwall Police
Cause of concern: Devon and Cornwall Police is too often failing to record reports of violent crime, particularly behavioural crimes (harassment, stalking, controlling and coercive behaviour), domestic abuse and anti-social behaviour. Recommendation: Devon and Cornwall Police should immediately take steps …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t taken sufficient action since the last inspection to appropriately resource its protection function. Recommendation: By 30 September 2021, the service should review its administration of the protection function to make sure it can record …
Recommendation
ICIBI Immigration Recommendations (18)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
An inspection of the Home Office’s use of sanctions and penalties
2. (Without waiting to complete any more comprehensive reviews), ensure that the quality and extent of record-keeping and data collection are sufficient to provide clear insights into the efficiency and …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
A further inspection of the EU Settlement Scheme July 2020 – March …
Recommendation 8 Collect and publish data for complaints received in relation to the EU Settlement Scheme (EUSS) and for Administrative Review applications and outcomes.
An inspection of illegal working enforcement (August – October 2023)
Implement a standardised procedure for recording debriefing records on PRONTO.
An inspection of contingency asylum accommodation for families with children in Northern …
The Home Office should review the effectiveness of the advice, issues reporting and eligibility (AIRE) contract, in particular the processes for capture of complaints and feedback from those living in …
An inspection of the use of deprivation of citizenship by the Status …
Data recording - Review mechanisms for recording case data to ensure that record keeping is consistent, quality assured, and it allows for proper analysis to inform planning.
An inspection of contingency asylum accommodation November 2023 – June 2024
Improve record keeping and data quality by agreeing the requirements and minimum standards for information and data recorded by the Home Office and by the accommodation providers (and subcontractors) relating …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to IECA performance and productivity: a) Review record-keeping in relation to RG and CG decisions and identify how performance reporting could be improved to provide qualitative as well …
An inspection of General Maritime (October 2024 – February 2025)
Create and maintain a centralised record of what training every Border Force officer has completed and their training needs (including for refresher training), readily accessible to regions and commands, so …
An inspection of Border Force operations at Stansted Airport
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
An inspection of Border Force operations at south coast seaports
Record information about searches and other activities conducted by Border Force at and from each port in a consistent format and in sufficient detail to improve knowledge of the threats …
An inspection of Border Force’s fast parcels operations (May–July 2023)
Introduce a digital solution to record all fast parcels examinations in real time, including the reasons for examinations to provide managers with sufficient management information to plan and assure activity.
PPO Death in Custody Recommendations (33)
The Governor of The Mount
The Governor of The Mount should ensure that all evidence, including electronic evidence, relevant to a death in custody is retained and made available to the PPO in line with PSI 58/2010.
The Governor of Isle of Man Prison
The Governor should ensure that the prison complies with its own policy for contacting the families of deceased prisoner and that they have adequately trained family liaison officers.
The Governor
The Governor should ensure that, following a death in custody, the family liaison officer (FLO) maintains an accurate log with all significant contacts and that the prison provide relevant documents when requested in line with PSI 58/2010.
The Director
The Director should ensure that family liaison officers record all family contact in the FLO log, including next of kin contact details, and provide it to the PPO investigator when requested.
The Governor
The Governor should ensure that all evidence about a death in custody, including electronic evidence, is retained and promptly made available to the Prisons and Probation Ombudsman, in line with PSI 58/2010.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that evidence is made available to the PPO, in line with PSI 58/2010.
The Governor
The Governor should ensure that prison staff provide all relevant information requested by the Prison and Probation Ombudsman’s office, in line with PSI 58/2010.
The Governor
The Governor should ensure that staff directly involved in a death in custody complete incident statements as soon as practicable following the death.
The Governor
The Governor should ensure that documents are retained, securely stored and promptly provided to the Prisons and Probation Ombudsman following a death in custody, in line with Prison Service Instruction 58/2010.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • All necessary paperwork explaining the decision to segregate is appropriately completed, stored, and made available in the event of a PPO investigation.
The Head of Healthcare
The Head of Healthcare should introduce a robust quality assurance process to ensure that prisoner applications are promptly responded to and healthcare staff record any action taken.
The Head of the National Approved Premises Team
The Head of the National Approved Premises Team should ensure that every death in an AP is subject to a local investigation and report similar to the process adopted in Southwest and South Central Region.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • prison staff record key information about their contact with prisoners on NOMIS, the prison records database, accurately and in a timely manner; and that • healthcare staff make contemporaneous records …
The NHS England – Southwest Commissioner
the NHSW Commissioner should inform the PPO of the outcome within six months.
The Governor
The Governor should ensure that all managers follow the national instructions for dealing with a death in custody or serious incident, including that all staff directly involved in an incident complete Incident Report Forms as soon as possible.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that the evidence is made available to the PPO, in line with PSI 58/2010.
The Head of Safety
The Head of Safety should ensure that there is a process in place for tracking and storing closed ACCT documents.
The Governor of HMP Hull
escort risk assessments are retained and stored securely in line with retention policies and General Data Protection Regulation (GDPR) requirements.
The Governor
The Governor should investigate what led to the documentation about Mr Boamah being lost and ensure that documentation is retained and stored securely in future.
The Head of Healthcare (HMP Erlestoke)
The Head of Healthcare should ensure that all contact and interventions with prisoners under the care of the substance misuse service are properly recorded.
The Governor
The Governor should ensure that documents are securely stored and promptly provided to the Prisons and Probation Ombudsman following a death in custody, in line with Prison Service Instruction 58/2010.
The Head of Healthcare
The Head of Healthcare should ensure that: formal care plans are in place to manage patients with chronic health conditions; and healthcare staff record the details and outcome of assessments in patients’ medical records; and follow the protocols for escalating …
The Director (HMP Peterborough)
The Director should ensure that the prison’s process for progressing and monitoring ERCG applications is reviewed so that applications are progressed in a timely manner.
The Governor
The Governor should ensure that staff directly involved in a death in custody complete incident statements as soon as possible after a death.
The Governor
The Governor should ensure that all information requested by the PPO following a death in custody is provided promptly.
The Head of Healthcare
The Head of Healthcare should develop a reporting tool to identify mental health referrals that are closed without action or explanation.
The Governor
The Governor should ensure that documents are securely stored and promptly provided to the Prisons and Probation Ombudsman following a death in custody, in line with Prison Service Instruction 58/2010.
The Governor of HMP Elmley
The Governor of HMP Elmley should review procedures for ordering monitoring tags for prisoners awaiting release, identify whether the error with Mr Corbett’s licence is a systemic issue and implement any necessary changes to mitigate this.
The Governor
securely retain risk assessment documentation.
Practice Plus Group
undertake a clinical audit of records made following an emergency response (after Mr Morgan’s death) to assess the quality of record keeping.
The Director of HMP Dovegate
The Director will want to ensure that managers continue to review and monitor the completion of these important interviews.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: review prisoners’ starting antidepressants in line with Royal College of General Practitioners’ guidance; record actions and decisions about a prisoner’s ongoing care in their medical record and check that the entries …
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should liaise with the hospital to develop a system to improve communication to ensure that changes in appointments are communicated effectively.
IOPC Learning Recommendations (25)
Recommendations - Metropolitan Police Service, August 2021
The IOPC recommends that the MPS DPS implements a system to monitor officer compliance with; In an investigation it became apparent there was documentation that could have negated the need for investigation, but it had not been recorded on the …
Recommendation - Surrey Police, April 2022
The IOPC recommends that Surrey Police updates relevant force policies relating to complaint handling [and body worn video (BWV) if appropriate] to include searching for BWV footage relevant to a complaint received and marking it as evidential as part of …
Recommendation - Lincolnshire Police, December 2022
The IOPC recommends that Lincolnshire Police should devise a unified, auditable process for handling unreasonable and unacceptable communications with service users. Consideration should be given to ensuring the process covers the needs of service users and how to fulfil them, …
Complaints made against a senior Lancashire police officer by two retired senior …
The IOPC recommends that Lancashire Police should ensure all policy decisions and rationales should be documented appropriately during the course of its investigations to record strategic decisions, operational priorities, and strategic, critical and investigative issues. This follows an independent IOPC …
Investigation into the West Yorkshire Police response to reports of injuries to …
The IOPC recommend that West Yorkshire Police (WYP) take steps to ensure that all officers and staff complete a NICHE (Occurrence Entry Log) with all relevant information OEL following a potential complaint of a crime and to ensure that all …
Recommendation - West Yorkshire Police, January 2026
The IOPC recommends that West Yorkshire Police implement a process for recording reasonable adjustments which a service user discloses to them, taking into account relevant data protection considerations. This follows a review where the complaint handler advised that the force …
Recommendations - West Yorkshire Police, February 2021
It is recommended that West Yorkshire Police (WYP) review their system for recording all radio transmissions in relation to authorised firearms deployments to ensure the actions and decisions of the Tactical Firearms Commander, Senior Investigating Officer, Authorised Firearms Officers and …
Recommendations - West Yorkshire Police, February 2021
The IOPC recommends that West Yorkshire Police (WYP) conducts a review of its scene management policies, procedures and training and where necessary make changes to ensure that where paper records are maintained those records are retained for production when required …
Recommendations - Suffolk Constabulary, October 2020
The IOPC recommended that Suffolk Constabulary takes appropriate action to satisfy itself that officers and staff are no longer completing multi-cell observations records and are complying with any change to force practices. This follows a DSI review in respect of …
Recommendations - Suffolk Constabulary, October 2020
The IOPC recommended that Suffolk Constabulary ensures that all custody officers and staff are reminded of the importance of accurate custody entries, and are made aware of any change to force practices concerning the recording of visits and observations. This …
Recommendations - Suffolk Constabulary, October 2020
The IOPC recommends that Suffolk Constabulary should stop the practice in its custody suites of making multi-cell observation records in individual detainee custody records. Entries on an individual custody record should only note observations in relation to that specific detainee’s …
Recommendation - Metropolitan Police, October 2020
The IOPC recommends that the Metropolitan Police Service create a policy for officers and staff to record ad hoc telephone conversations with victims of crime, post charge of a suspect. The policy should allow officers to re-open Crime Reporting Information …
Recommendation - Sussex Police, February 2021
The IOPC recommends that Sussex Police ensures formal guidance and policies are in place in relation to the storage of both physical and electronic investigative material obtained during an investigation, if it is not already, ensuring a consistent approach which …
Recommendations - Cleveland Police, February 2021
The IOPC recommends Cleveland Police assess whether it is feasible to provide a solution to enable members of staff to record the reason for checks when they are not directly involved in an incident. The Niche administrator for Cleveland Police …
Man died while in police custody – Nottinghamshire Police, June 2017
The IOPC recommends that Nottinghamshire Police remove the option of a drop-down menu when entering cell observation entries onto the custody log, or otherwise introduce a prompt to the system which reminds detention officers of the need to input further …
Investigation into police contact before death - Devon and Cornwall Police, July …
The IOPC recommends that Devon and Cornwall Police ensure that the time a check is conducted on a prisoner is recorded on the custody record in addition to the computer generated time shown when the update is added. The detention …
Recommendations - Wiltshire Police, September 2021
The IOPC recommends that Wiltshire Police reviews its document management and record keeping practices in relation to the Domestic Violence Disclosure Scheme (DVDS) to ensure that all research undertaken is recorded and the rationale for any decisions made is recorded, …
Recommendations - Bedfordshire Police, July 2021
The IOPC recommends that Bedfordshire Police reviews the current process of medical examinations being documented on paper records when problems are encountered with the Athena system, to ensure that copies of the paper records are shared immediately with custody sergeants …
Recommendations - Metropolitan Police Service, July 2021
The IOPC recommends that the Metropolitan Police Service (MPS) should conduct a formal review of the custody procedures regarding the safekeeping of seized evidence before it enters an evidential store. It is important that the procedures in place are sufficiently …
Reports of domestic incident prior to child sustaining serious injuries - Greater …
The IOPC recommends that GMP reminds control room staff of the importance of accurately recording information provided during calls so that it can be communicated to attending officers and used to inform decision making and incident management. A number of …
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that Hampshire Constabulary takes steps to ensure the microphones covering the booking in desks are in good working order, to ensure information communicated at the booking in desks is audibly captured. In addition, the force should review …
National recommendations and recommendations made to the Metropolitan Police Service - October …
In the case of Operation Midland, the rolling log of key consistencies and inconsistencies in X's evidence was a key document. Attempts to establish when and how the document was updated were critical to our enquiries. These were hampered by …
Recommendation - West Yorkshire Police, February 2020
The IOPC recommends that West Yorkshire Police amend their Standard Operating Procedure called ‘Forensic examination of digital devices and electronic networks – supporting information document’ to say that, if a memory device is left in computer equipment at the time …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police implement a supervision policy around the closure of incident logs. In this particular case, two staff members were not clear as to who could close an incident where the original classification code was different …
Recommendation - West Yorkshire Police, March 2023
The IOPC recommends that West Yorkshire Police (WYP) amends or creates policies and procedures in respect of acknowledging receipt and return of evidence from members of the public to ensure that they include a strategy for the receipt and return …
NAO Audit Recommendations (16)
Child Maintenance Client Funds Accounts 2020-21: 1993 and 2003 Schemes Account
For the 1993 and 2003 schemes, the Department should continue to review the service it is providing to parents and ensure that it: • maintains adequate records and has a clear process to support parents who have concerns around the …
Accepted
Child Maintenance Client Funds Account 2019-20
For the 1993 and 2003 schemes, the Department should continue to review the service it is providing to parents and ensure that it: • maintains adequate records and has a clear process to support parents who are concerned that arrears …
Accepted
Child Maintenance Clients Fund Account 2018-19
• ensure adequate records and systems are maintained until all arrears are written off or collected, and these schemes can be brought to a full close.
Accepted
Child Maintenance Clients Fund Account 2018-19
To improve customer service, the Department should: • establish a clear process to support parents who are concerned that arrears balances now being collected are inaccurate; and
Partially accepted
Investigation into NHS Property Services Limited
b) put in place an efficient dispute resolution process whereby all disputes are settled within 90 days of invoicing and agree a plan to clear outstanding disputes including a service-level agreement for responding to queries from tenants in a reasonable …
Partially accepted
Child Maintenance Client Funds Account 2019-20
To enhance accountability and reporting, the Department should: • take steps to ensure maintenance collected can be allocated to schemes and cases, to support accurate reporting and prompt payment to parents with care; and
Accepted
Investigation into NHS Property Services Limited
h) review its capacity to deal with queries in an effective and timely manner.
Accepted
Investigation into NHS Property Services Limited
The Department, in collaboration with national bodies and the Service should: a) develop a plan to ensure that the Service and all tenants of the Service’s premises will agree tenancy details and amounts by 31 March 2020; and
Accepted
Transforming health assessments for disability benefits
DWP should: b produce interim target operating models for the Programme at appropriate stages and continue to develop its test-and-learn approach including: putting in place the mechanisms to provide feedback to healthcare professionals and decision-makers and helping assure the consistency …
Accepted
Child Maintenance Client Funds Account 2021-22
allocates sufficient resource to provide appropriate customer service and timely responses to queries and complaints on cases
Accepted
Child Maintenance Client Funds Account 2021-22
maintains adequate records and has a clear process to support parents who have concerns around the accuracy of arrears balances that are now being collected
Accepted
Gambling regulation: problem gambling and protecting vulnerable people
f) review whether the arrangements for consumers when things go wrong are working effectively. This should include consideration of whether simplifying dispute resolution services would make it easier and more consistent for consumers to access them, and whether it would …
Accepted
Investigation into NHS Property Services Limited
g) continue to reduce the time it takes to issue bills; and
Accepted
DWP customer service
To improve its customer service, DWP should build its evidence base on the scale and type of avoidable customer contact, and develop a plan to improve its processes and communications in order to reduce avoidable contact and realise efficiency savings.
Accepted
DWP customer service
To improve its customer service, DWP should publish comprehensive reports which bring together annual performance, trends over time and whether it has exceeded or fallen short of its standards for its main customer service measures (customer satisfaction, payment accuracy, payment …
Partially accepted
DWP customer service
To improve its customer service, DWP should review the effectiveness of how it communicates claim-processing and call-waiting times to customers, and identify how it can provide fuller and more up-to-date information, at the point of claim and during other key …
Partially accepted
Victims' Commissioner Recommendations (8)
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Ministry of Justice undertake a review of the victim journey with a view to exploring options for better delivery of Victims’ Code rights and communication, including exploration of a ‘single point of contact’ liaison or navigator that has …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: HMCPSI and HMICFRS jointly carry out a review of victim-facing communications, from the time the case enters the court system up to, and including, sentencing. This review should consider the quality and consistency of communications. Read recommendation detail Given …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The National Police Chiefs’ Council should issue guidance to Chief Constables to ensure that Witness Care Units/ police staff are undertaking thorough victim needs assessments, which fully recognise the impact delays in the court system can have on victim …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Crown Prosecution Service must ensure any additional vulnerabilities which could be exacerbated by delay are assessed by the Witness Care Unit/police staff and are then communicated as part of the plea and trial preparation hearings, and any subsequent …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Ministry of Justice must update the Victims’ Code to make clear that needs assessments should be ongoing during the court process. The effect of delay on the individual victim must also form part of that assessment in order …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Ministry of Justice commence the provisions in the Victims and Prisoners Act (2024) relating to victim information requests at the earliest opportunity, to ensure the new threshold for seeking notes of therapy is implemented. The Ministry of Justice …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Crown Prosecution Service reviews and updates its guidance on pre-trial therapy to reflect the new threshold and to ensure CPS staff provide victims with accurate information about their rights, to help inform their decision about whether to proceed …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The National Police Chiefs’ Council update their guidance and the Soteria national operating model to ensure that police staff are aware of the new threshold and are able to provide victims with accurate advice on their right to access …
IMB Annual Reports (7)
Onley (2020)
HMP Onley experienced a challenging year with a restricted regime, largely due to staffing shortages, though improvements were seen towards the end. Key concerns include significant issues with property transfers, a dysfunctional complaints process, and a lack of purposeful activity leading to prisoners spending extended periods in their cells. The Board highlights persistent problems with resettlement progression, including missing OASys reports and slow transfers, alongside concerns about drug availability, self-harm incidents, and the general state of the estate. While staff-prisoner relationships improved and the OMiC model showed promise, the report calls for urgent action on staffing, regime provision, and inmate progression.
PRISON
Key concerns
Lindholme (2020)
HMP Lindholme is a Category C training prison with an operational capacity of 1,010. The report highlights improvements in security, segregation management, and some aspects of healthcare, including reduced GP waiting times. Key concerns persist regarding organised crime's impact on safety, substance misuse, delayed complaint responses, and the high number of IPP prisoners. Staffing, particularly for key worker roles and healthcare provision, continues to be an area requiring significant development.
PRISON
Key concerns
Yarl’s Wood (2021)
This IMB annual report for Yarl’s Wood IRC covers 2021, a challenging year marked by the Covid-19 pandemic and the transition to accommodate predominantly male detainees. The Board commends the centre's management for maintaining a safe environment with low Covid-19 cases, high quality healthcare, and generally fair treatment. However, significant concerns remain regarding the identification and support of vulnerable individuals, the clarity of induction for short-stay detainees, and the comprehensive tracking and resolution of complaints.
PRISON
Key concerns
Askham Grange (2024)
HMP/YOI Askham Grange is generally a safe and positive environment for women, with excellent staff-prisoner relationships, no self-harm incidents, and no use of force. While healthcare provision is good, concerns persist regarding accessibility and transparency of the complaints process, and issues with medication dispensing lockers. The prison excels in purposeful activity and resettlement, yet faces challenges with maintaining capacity and ensuring prisoners arrive with sufficient time to fully benefit from open conditions.
PRISON
Key concerns
Lindholme (2022)
HMP Lindholme continued to operate under COVID-19 restrictions, limiting regime and purposeful activity, yet saw the successful implementation of digital infrastructure and in-cell phones. While healthcare provision improved with reduced waiting times in most areas, significant concerns remain regarding persistent overcrowding, the high number of IPP prisoners, and the inadequate provision of resettlement services. Issues with the timely handling of prisoner complaints and property also need further attention.
PRISON
Key concerns
Wakefield (2022)
HMP Wakefield, a high-security prison for men, is generally considered safe but experienced increases in assaults and use of force. Key concerns include persistent issues with mental health transfers, a lack of robust healthcare complaints processes, and the absence of in-cell telephony. The Board also highlighted unsatisfactory property management and insufficient purposeful activity for prisoners.
PRISON
Key concerns
Peterborough (2025)
HMP/YOI Peterborough saw significant improvements in staff recruitment, regime delivery, and healthcare provision, with self-harm management remaining professional. However, the Board remains concerned about inconsistent and poor quality responses to prisoner complaints, poor professional standards among some managers, and persistent issues with medication distribution and social care referrals. The prison faces substantial challenges in adapting to a predominantly remand population for men and differentiating the women's regime.
PRISON
Key concerns
IMB Recommendations (504) — showing 50 strongest matches
Onley (2020)
The speed with which prisoner complaints have to be dealt with often results in responses that have not been carefully considered. Prisoners need to have confidence in this process.
HMPPS
Lindholme (2020)
Will the Governor ensure that prisoners’ complaints are dealt with in a timely manner and that, at the very least, a holding response is given to every complaint when it is received (see Survey Questionnaire 9b)?
Governor / Director
Lancaster Farms (2020)
There was a significant increase, in the second half of the year, in the number of complaints for which a response is overdue. This raises serious concerns regarding the allocation of resources to this activity (see paragraph 7.8).
Governor / Director
Berwyn (2020)
Responses to complaints (that is, Comp 1 and Comp 1a) are an issue in the establishment. If prisoners were kept informed of progress, it could reduce frustration, including additional Comp 1as and applications to the Board and the chaplaincy.
Governor / Director
Yarl’s Wood (2021)
The Board recommends that a centralised complaints-tracking database is introduced, to ensure that all complaints, regardless of the agency involved, can be shown to have been investigated within the allocated time frame and a reply sent to the complainant. The database should also link the complaint and response correspondence to each case and be accessible to agencies at the centre.
Home Office
Guys Marsh (2022)
The management of the complaints process improved markedly but responses to complaints continued to be disappointingly slow. Can the Governor assure the IMB that this will change in the immediate future?
Governor / Director
Bedford (2022)
Performance on complaints has got worse and prisoners tell us that they have little confidence in the system.
Governor / Director
Gatwick IRC (2023)
Review the complaints’ management systems for the healthcare unit to ensure there is adequate accountability to the men using the services.
NHS / Healthcare Provider
Gatwick IRC (2023)
Review the operation of the process for handling complaints against Serco, including factors behind withdrawal rates, considering changes such as introducing specialist teams to handle complaints, shortening the time for responses, and whether contractual penalties can be modified.
Home Office
Gatwick IRC (2024)
Provide more transparency about healthcare complaints and shorter timeframes for response. Provide adequate information to allow the IMB to assess the nature of the complaints and the effectiveness and efficiency of this complaints process.
NHS / Healthcare Provider
Bronzefield (2024)
The number of complaints not answered within the timelines contained in the Prisoner Complaints Policy Framework continues to be of concern to the Board and has resulted in prisoners losing confidence in the system. What will the prison do to address this issue? (5.7)
Governor / Director
Yarl’s Wood (2020)
The Board recommends that, subject to the agreement of the complainant, the DES Complaints Team ensure all agencies fulfil their obligation to share complaints and their outcomes with the Board so that the Board can monitor the rigour of the investigation, and the timeliness and fairness of outcomes for detainees. The Board also recommends that all complaint resolutions are automatically …
Home Office
Wealstun (2020)
Ensure that Care UK has a process for replying to prisoner complaints within an agreed timescale (see paragraph 6.1.3).
Governor / Director
Thameside (2020)
The Director should overhaul investigations into prisoner allegations against staff, ensuring they are timely, reach meaningful conclusions, and provide valid responses to prisoners.
Governor / Director
Manchester (2020)
What processes can be implemented to improve the quality of responses to those prisoners making a complaint?
Governor / Director
Belmarsh (2020)
Will the prison implement recommendations 26 and 27 of the 2017 Lammy Review in its handling of all complaints, not just discrimination complaints, and change the process for complaints to accommodate them (see section 5.7)?
Governor / Director
Bedford (2020)
Request that the healthcare team provides the Board and prison managers with monthly data regarding the number of complaints submitted to NHFT relating to the healthcare and mental health teams (separately).
Governor / Director
Swaleside (2021)
The Board asks the Governor to note the high level of applications we have received complaining about staff. These should have translated into complaints sent to him and the DDC, and are at a much higher level than last year. (see section 8)
Governor / Director
Send (2021)
The Board has identified that complaints in March 2021 have been stamped in batches indicating that boxes on wings were not being emptied nightly: this delay would impact on true response times (5.7).
Governor / Director
Huntercombe (2021)
For a more robust audit system to be operated as regards the complaints log, and for complaints beyond their response date to be consistently pursued (paragraph 5.7.2.).
Governor / Director
Hewell (2021)
Improve the handling of prison complaints and applications systems, focusing particularly on those which raise issues of discrimination, to ensure that such concerns are appropriately addressed and where necessary dealt with through the DIRF process.
Governor / Director
Belmarsh (2021)
Will the prison review the prisoner complaints process, as suggested in the IMB Annual Report of last year (see section 5.7 Complaints)?
Governor / Director
Wakefield (2022)
In our 2020-21 annual report we asked HMPPS to clarify if the complaints procedure for healthcare provision at HMP Wakefield is audited in line with standard complaints made under the COMP1/2 procedures. The Board is not satisfied with the procedures for dealing with prisoner complaints (or concerns). We ask HMPPS to clarify what action is being taken to remedy this …
HMPPS
Preston (2022)
The backlog of Comp 1 forms needs addressing.
Governor / Director
Oakwood (2022)
During the reporting year the Board has been concerned that the healthcare complaint boxes were not emptied on a regular basis and their location is not easily accessible to all prisoners at all times. The Board asks the Director to review this with the head of healthcare (see para 6.1).
Governor / Director
Lindholme (2022)
We recommend that the matter be reviewed in order to improve prisoners’ confidence in the complaints system.
Governor / Director
Gatwick IRC/RSTHF (2022)
Share the contents of complaints against Healthcare, having redacted clinical information, and responses to them (sections 5.7, 6.1).
NHS / Healthcare Provider
Gatwick IRC/RSTHF (2022)
Share the contents of complaints against the Home Office, and their responses (section 5.7).
Home Office
Frankland (2022)
What actions are in place to improve the complaints response times?
Governor / Director
Downview (2022)
The Board has little confidence in how healthcare complaints and concerns are managed and logged and we hope to see a more efficient system being developed.
Governor / Director
Sudbury (2023)
The Board has noted a substantial number of complaints which were not processed by the deadline. What measures can be put in place to address this?
Governor / Director
Parc (2023)
Ensure the complaints system functions and monitor that responses are received within the required time scales.
Governor / Director
Oakwood (2023)
Can the Director consider what further steps can be taken, in addition to quality checks that are already being carried out, to improve the quality and legibility of the responses to complaints? Some replies neither address the complaint nor indicate what follow up has been completed.
Governor / Director
Liverpool (2023)
Prisoners are not receiving responses to complaints from other establishments within the timeframes specified in Prison Service policies. Some prisoners have been waiting for more than two years. What will the Prison Service do to ensure that this inadequacy is addressed and prevented?
HMPPS
Littlehey (2023)
There has been a noticeable increase in the number of complaints at HMP Littlehey. The Board would like to be made aware of the processes in place to identify any trends in these complaints.
Governor / Director
Hewell (2023)
Monitor complaints by prisoners more rigorously, note the wide variation and quality of responses from staff, in particular the tone, an indicator of whether the desired culture change is being achieved throughout the prison. Improve the thoroughness of recording and responding to complaints about staff behaviour.
Governor / Director
Gatwick IRC (2023)
Share the contents of complaints against the healthcare unit, having redacted clinical information, and responses to them.
NHS / Healthcare Provider
Gatwick IRC (2023)
Share the contents of complaints – and their respopnses – against the Home Office.
Home Office
Downview (2023)
healthcare complaints management.
Governor / Director
Coldingley (2023)
Complaints from prisoners provide a vital insight into aspects of prison life which are not working well. There is evidence that there are has been a deterioration in quality of response to complaints, with many prisoners stating 'there is no point'. What plans does the Governor have to improve the system and restore trust in the prisoners that they will …
Governor / Director
Bronzefield (2023)
How does the prison plan to ensure that complaints are handled in line with the Prisoner Complaints Policy Framework?
Governor / Director
Stoke Heath (2024)
Can prison complaints be answered clearly in a timely manner, by the right person and at the appropriate level?
Governor / Director
Pentonville (2024)
Will you commit to reinstate auditing of the quality of responses sent by the prison to prisoner complaints?
Governor / Director
London STHF (2024)
The Board is of the opinion that one person or a team should be made responsible for sending out a consolidated reply that incorporates replies to the complainant from all agencies.
Home Office
Coldingley (2024)
The DIRF system must be seen as fair and independent so prisoners feel confident to use it. Will an external auditor be appointed as soon as possible?
Governor / Director
Oakwood (2025)
Can the Director work with health champions and members of the HAS Line, a prisoner-led initiative which works with Healthcare, to address the issue of the availability of health complaint forms on the houseblocks?
Governor / Director
Oakwood (2025)
Can the Director work with the Development and Assurance (D & A) department to address the issue of the availability of prison complaint forms on the houseblocks?
Governor / Director
Lindholme (2025)
The Board asks that a review be undertaken of submission and collection process for prisoner complaint forms (Comp1s, Comp1As/appeal forms, DIRFs/discrimination incident reporting forms) in order to raise prisoner trust and confidence.
Governor / Director
Lindholme (2025)
The Board asks that a review be undertaken of submission and collection process for prisoner complaint forms (Comp1s, Comp1As/appeal forms, DIRFs/discrimination incident reporting forms) in order to raise prisoner trust and confidence.
Governor / Director
Gatwick IRC (2021)
Operation of the process for complaints against Serco should be reviewed, including factors behind withdrawal rates, and this should consider changes such as introducing specialist teams to handle complaints, shortening the time for responses, and whether contractual penalties for substantiated complaints can be modified (section 5.7).
Home Office
Health Investigations (2)
Independent investigation into the care and treatment of Mr L — Rec 5
The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about: the type of records to be created and stored when conducting an internal investigation; storage and retrieval of clinical records, and reporting of misplaced clinical records, …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 5
The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about: the type of records to be created and stored when conducting an internal investigation; storage and retrieval of clinical records, and reporting of misplaced clinical records, …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Article 2 Learning Points (13)
— LP 6
Archived records in accordance with PSO 9020 should be more clearly indexed to facilitate future investigations.
HMPPS
— LP 7
I recommend that NOMS reviews the guidance to establishments about action following life-threatening incidents of self-harm to ensure that it makes clear that evidence must be preserved.
NOMS
— LP 6
We draw to the attention of the Governor of HMP Chelmsford deficiencies in the collection, recording and preservation of evidence that we have found in this case.
The Governor
Accepted
— LP 2
If they have not already done so, NOMS and HMP Whitemoor should consider if current procedures and staff training provide for the full and accurate completion of official prison documents. Adequate audit and storage arrangements should also be considered as part of any subsequent review. The investigation highlighted a high …
NOMS and HMP Whitemoor
Accepted
— LP 11
Managers at HMP Birmingham should remind prison staff in contact with prisoners of the importance of documenting events in a prisoner’s Prison National Offender Management Information System record.
The Governor
Accepted
— LP 18
The list of documents to be retained as set out in PSI 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults where an independent investigation will be necessary should mirror that in PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from …
HMPPS
Accepted
— LP 17
All relevant documentation relating to a prisoner following an incident that may result in an investigation under Article 2 should be promptly secured.
HMPPS
Accepted
— LP 4
HMP Norwich should formally include a standing item on the safer custody meeting agenda to review progress on outstanding simple investigations.
HMP Norwich
Accepted
— LP 3
HMP Norwich should review its record keeping procedures to ensure documents are stored in a way that they can be retrieved and produced on request
HMP Norwich
Accepted
— LP 1
HMPPS should update PSI 15/2014 (which has an expiry date of 02 April 2018). Consideration should be given to: • requiring governors to complete any simple investigation within three months of the incident, or provide an update on the progress of the investigation at three monthly intervals • facilitating the …
HMPPS
— LP 3
HMP Featherstone should comply with the mandatory action contained in Prison Service Order 1300 – ‘Investigations’ that a formal investigation is completed when there is serious harm to any person.
HMP Featherstone
Accepted
— LP L
When prisoners raise medical issues in adjudications, the information should be passed on to the appropriate health care services.
HMPPS and PPG
— LP 6
When a prison security department receives critical security information from a sending establishment outside the prescribed timescales, this should be communicated to the Governor at the sending prison so that remedial action is taken to rectify any system failures.
HMPPS
Accepted
Detention Investigations (13)
Investigation into the Failing of Medomsley Detention Centre — Rec 2
The second is around the complaints process for children in custody. I have made a notable observation that the system for children to make a complaint in today’s criminal justice system remains broadly the same as the system in place when Medomsley operated. To make a complaint, children must write …
Prisons
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 49
IND reviews complaint handling in removal centres with a view to establishing greater consistency. The review should take account of procedures for recording complaints. Records should show what the complaint was, when it was made, when resolved and what the resolution was.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 54
I recommend that IND establishes the office of Prisons and Probation Ombudsman on an administrative basis as the independent tier of its detainee complaints system as a matter of priority. The Ombudsman should be required expressly to act as guardian of the whole complaints system and funded accordingly.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R52
The SMT should ensure that a single log is kept of all allegations or instances of misconduct by staff and the actions taken in respect of them. (To be completed within 3 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 53
I recommend that a separate resource is identified and properly trained to handle complaints and associated work.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 1
I recommend that all complaints of racism at Oakington, however dealt with, are formally recorded.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 19
I also recommend that those who raise issues or grievances are given regular progress reports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 18
I recommend that senior managers ensure that strict deadlines are adhered to when progressing complaints and grievances.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 25
I recommend that the Home Office commission a formal review of the quality of PERs and that any deficiencies are addressed. In the meantime, all staff should be reminded of the importance of completing PERs fully.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 52
I recommend that a module on complaints handling and investigation is incorporated in the training package for contract monitors.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 24
The Home Offce should strengthen its data monitoring processes and quality assurance for the detention gatekeeper and case progression panels. In particular, it should ensure that the outcomes following case progression panels are tracked and reported.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 74
contractors be required to include in their contingency plans the steps they will take following an incident of this kind to ensure that detainees know how to claim for lost property. The plans should include the identity of a named individual who will be responsible for addressing and resolving all …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 48
I recommend that all contractors carry out ethnic monitoring of all complaints, overseen by the respective contract monitors.
Immigration Detention
PHSO Casework Decisions (632)
P-001244 — A medical practice in the Manchester area
Mr E complained about the Practice's handling of his complaint between January 2018 and September 2019.
NHS in England
Upheld
Aug 2021
P-001151 — A medical practice in the Croydon area
Mr A complains a medical practice in the Croydon area failed to offer him a COVID-19 vaccination as a priority, despite his underlying health condition (severe asthma). He also complains that a GP hung up on him during a phone call, did not record the call and about the layout …
NHS in England
Oct 2021
P-001380 — A medical practice in the Derbyshire area
Mr I complained about the care and treatment he received from a medical practice in the Derbyshire area. He says staff were abusive towards him for not wearing a face mask, and they refused to carry out the blood tests he needed. He also complains about the Practice's complaint handling, …
NHS in England
Apr 2022
P-001439 — NHS Surrey Heartlands
Ms R complained about NHS Surrey Heartland's Integrated Care Board's handling of the complaints she raised in February 2020.
NHS in England
Jun 2022
P-003196 — Department for Education
Mr I complains about the Department for Education and the way it handled his complaint.
UK Government
Dec 2024
P-003210 — Information Commissioner's Office
Mr T complains about how the ICO dealt with his complaint about a property developer breaching data protection regulations. Mr T says the ICO did not act in line with its service standard when he complained about its service.
UK Government
Dec 2024
P-003695 — HM Revenue and Customs
Mr N complains that HMRC have not taken action to ensure a company working on its behalf as a debt collection agency deals with his complaints effectively.
UK Government
Jul 2025
P-002416 — NHS England
Mr I complains NHS England did not take his complaint about his dental practice seriously and delayed responding to him.
NHS in England
Jan 2024
P-002517 — A practice in the Barnet area
Mr O complains the Practice did not provide a response to his complaints despite repeated attempts to raise concerns between December 2022 and November 2023.
NHS in England
Partly Upheld
Mar 2024
P-002543 — Harrogate and District NHS Foundation Trust
Mr Y complains the Trust did not reinvestigate his past complaint after he submitted new information on 16 January 2023.
NHS in England
Apr 2024
P-003126 — Leicester, Leicestershire and Rutland Integrated Care Board
Mr M complains about poor communication and the time it took the ICB to respond to his complaint.
NHS in England
Nov 2024
P-003106 — Black Country Integrated Care Board
Ms F complains Black Country Integrated Care Board mismanaged her complaint about a continuing healthcare checklist it completed for her mother.Findings leading to recommendationsWhat we are asking the ICB to do for Ms F.Complaint issueWhat we foundWhat the organisation should doWhat we need to see and whenComplaint handlingThe ICB failed …
NHS in England
Upheld
Nov 2024
P-003324 — Greater Manchester Integrated Care Partnership
Dr G complains the ICP did not investigate his complaints properly, or in some cases, respond to him at all.
NHS in England
Feb 2025
P-004784 — A practice in the Oadby and Wigston area
Ms A says the Practice placed her mother, Mrs X, nil by mouth on 14 November 2022 without a proper assessment and left her facing a potential five day wait for a SALT review. She reports that the Practice communicated poorly and took too long to respond to her complaint. …
NHS in England
Upheld
Feb 2026
P-004785 — A practice in the Torbay area
Mr A complains a Practice in Paignton incorrectly completed his father’s death certificate, did not provide the amended certificate without cost and did not deal with his complaint in line with its own complaint procedure.
NHS in England
Feb 2026
P-004694 — Torbay and South Devon NHS Foundation Trust
Mr N complains the Trust did not properly respond to his complaint following his wife's death.
NHS in England
Jan 2026
P-004697 — Oxford Health NHS Foundation Trust
Ms O complains about the conduct and attitude of members of the Trust's crisis team, and that they acted unprofessionally and unskilled between January 2023 to March 2024. She also complains the Trust refused to formally investigate and respond to her complaints of January 2024.
NHS in England
Jan 2026
P-001193 — A medical practice in the Milton Keynes area
Ms R complains a medical practice in the Milton Keynes area inadequately handled her complaint about the care and treatment provided to her father, Mr A, by district nurses during a home visit in February 2019.
NHS in England
Upheld
Jun 2021
P-001141 — A medical practice in the Tameside area
Mrs E complains the Practice falsely classed her letters as complaint letters and did not give her copies of these when she asked for them.
NHS in England
Resolution
Oct 2021
P-001320 — Barts Health NHS Trust
Ms U complained that Barts Health NHS Trust referred her from one doctor to another and prescribed unnecessary treatment without resolving her follicle condition. She also complained about delays in the Trust’s complaint handling.
NHS in England
Mar 2022
P-001438 — University Hospitals Coventry and Warwickshire NHS Trust
Mr A raises various complaints about the care and treatment provided to his late partner, Mrs O, at the University Hospitals Coventry and Warwickshire NHS Trust (the Trust) between 12 January 2020 and 11 February 2020. Mr A also complains about the way his complaint has been handled by the …
NHS in England
Upheld
Jun 2022
P-001199 — Children and Family Court Advisory and Support Service
Mr E complains about Cafcass. He specifically complains about the safeguarding letter, the conduct of the FCA and how his complaint was handled.
UK Government
Nov 2021
P-001317 — Independent Assessment Services
Mr H complained the Independent Assessment Service (IAS) failed to provide the CCTV footage he requested from his PIP assessment. He says this meant he was unable to prove the information about his mobility in the PIP assessment report was incorrect.
UK Government
Nov 2021
P-001473 — HM Revenue & Customs
Mr A complains the debt recovery action taken by HMRC in relation to the alleged underpayment was both unnecessary and poorly managed. Mr A is also unhappy with HMRC’s complaint handling.
UK Government
Not Upheld
Jul 2022
P-001703 — Information Commissioner
Mr O complains the ICO failed to respond to concerns he raised about third party organisations within its agreed timescales. He complains that when he then complained to the ICO about this, it did not respond to his complaints within its agreed timescales.
UK Government
Jan 2023
P-002692 — Information Commissioner's Office
Mr M complains ICO took too long to issue a decision notice on his complaint about how the Cabinet Office responded to his Freedom of Information (FOI) request.
UK Government
Jun 2024
P-003351 — Office of Qualifications and Examinations Regulation (Ofqual)
Mrs P complains that despite submitting further evidence to Ofqual in July 2024 it refused to carry out an internal review of its decision.
UK Government
Feb 2025
P-003993 — Child Maintenance Service (CMS)
Mr R complains about CMS's failure to carry out a mandatory reconsideration and asset valuation between 2018 and 2024. Furthermore, he says CMS failed to provide call backs, gave him incorrect information and it failed to investigate his concerns regarding his ex-partners income.
UK Government
Sep 2025
P-004171 — Independent Case Examiner
Mrs A complains ICE refused to consider her complaint about DWP. She says she did not receive DWP’s final response until 17 months after it was issued but ICE still considered her complaint to be out of time.
UK Government
Oct 2025
P-001727 — Frimley Health NHS Foundation Trust
Mrs L complains about the Trust's treatment and care of her husband. She also complains about its lack of advice, communication and how it handled her complaint.
NHS in England
Upheld
Jan 2023
P-002267 — Liverpool Heart and Chest Hospital NHS Foundation Trust
Miss B complains about how the Trust treated her when she made a complaint after her mother’s death.
NHS in England
Oct 2023
P-003047 — Cornwall Partnership NHS Foundation Trust
Mr N complains Cornwall Partnership NHS Foundation Trust failed to provide him with an emotional coping skills course for his mental health despite him being referred in 2018. He is also unhappy with how the complaint was managed as the Trust changed the upheld complaint to partly upheld without an …
NHS in England
Upheld
Sep 2024
P-003142 — NHS Resolution
Mr B complains about how NHS Resolution handled his complaint about a Trust.
NHS in England
Nov 2024
P-003482 — University Hospitals of Leicester NHS Trust
Mrs O complains the Trust has not provided evidence of the implemented change of procedure and learning it outlined in its complaint response.
NHS in England
Apr 2025
P-003728 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Mrs O complained that the Trust mishandled her complaint between January 2022 and July 2023. She says it took too long to respond, did not ensure the investigation was independent, did not respond to all points of the complaint and withdrew her care while the complaint was ongoing.
NHS in England
Partly Upheld
Jul 2025
P-003799 — A dental practice in the Mid Suffolk area
Mrs K complains about the Practice's service between July and November 2023. She is unhappy about a temporary denture that was fitted, appointments being cancelled and being stopped from attending the Practice after she made a complaint.
NHS in England
Upheld
Aug 2025
P-004286 — NHS England - South (South East)
Mr X complains about how NHS England has considered his mother's claim for continuing healthcare funding. He complains NHS England has failed to disclose important records which confirmed that the full period of his mother's condition would be reviewed.
NHS in England
Nov 2025
P-004392 — A practice in the Mansfield area
Mr R complains the Surgery were dismissive of his health concerns, provided him with inadequate advice, and did not resolve his complaint before closing it.
NHS in England
Dec 2025
P-004414 — University College London Hospitals NHS Foundation Trust
Miss F complains about the care and communication she received from the urology team at University College London Hospitals NHS Foundation Trust between August 2022 and April 2024. She specifically complains the Trust did not update or respond to her concerns when asking for help for a reoccurring infection, gave …
NHS in England
Dec 2025
P-004529 — Croydon Health Services NHS Trust
Ms N complains about the care and communication provided by the Dermatology department at Croydon Health Services NHS Trust in 2024-2025. She says poor communication, delays in appointments, and insufficient complaint handling led to distress, frustration, and a breakdown of trust in the quality of care she received.
NHS in England
Dec 2025
P-004772 — University Hospitals Coventry and Warwickshire NHS Trust
Mr A complains about aspects of his late father's care and treatment, and the Trust's complaint handling process.
NHS in England
Feb 2026
P-004761 — HM Revenue and Customs
Mr D complained about HMRC collection of an income tax underpayment and interest charged for late repayment.
UK Government
Jan 2026
P-004763 — HM Revenue and Customs
Mr N complains that HMRC has not correctly applied part 1300 of its Admin Law Manual (ADML1300) to his case. He also considers HMRC’s consideration of this issue is not in line with our Principles for Remedy and the HMRC Charter.
UK Government
Jan 2026
P-004660 — Office for Standards in Education, Children's Services and …
Mr E complains about Office for Standards in Education (Ofsted) and the Department of Education’s (DfE) complaint handling regarding the concerns he raised about a school between 2019 and 2022.
UK Government
Jan 2026
P-004664 — Children and Family Court Advisory and Support Service …
Mr S complains about a Section 7 report produced in December 2022, alleging the family court adviser (FCA) was biased. He also complains that Cafcass did not replace the FCA.
UK Government
Jan 2026
P-004679 — Health and Safety Executive
Mr N complains that the Health and Safety Executive (HSE) rejected his complaint about an Authorised Inspector. He also complained about how the HSE dealt with his complaints.
UK Government
Jan 2026
P-004681 — Teaching Regulation Agency
Mr H complains about the length of time the TRA took to reach a decision for a Professional Conduct Panel (PCP). Mr H also complains about the decision to impose an Interim Prohibition Order (IPO).
UK Government
Jan 2026
P-004691 — Leeds Teaching Hospitals NHS Trust
Mr A complains about the actions of Leeds Teaching Hospitals NHS Trust in relation to the handling of a subject access request and the management of his position on the waiting list for a knee replacement.
NHS in England
Jan 2026
P-004650 — Consumer Council for Water (CCW)
Mr A complains about the Consumer Council for Water (CCW) and its decision not to thoroughly investigate a complaint he had made about a Water Company. He says its view (that this is a private matter) was overly influenced by the Water Company and did not take full account of …
UK Government
Jan 2026
P-004655 — HM Revenue and Customs
Mr A complains HMRC has not properly responded to his requests for information in relation to its attempts to recover alleged overpayments of tax credits.
UK Government
Jan 2026
LGO / SPSO Decisions (8842)
24-021-176 — Nottinghamshire County Council
Summary: Mrs X complained the Council did not properly decide whether to prosecute a trader she complained about. We found the Council was at fault as it did not keep records showing how it decided not to prosecute the trader. To remedy the injustice caused the Council agreed to apologise …
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2025
201304283 — A Medical Practice in the Greater Glasgow and …
Ms C, who is an advice worker, complained to the medical practice on behalf of her client (Mr A) about his care and treatment. Ms C said she wrote to the practice several times, and phoned them, but they did not reply. Because of that, Ms C complained to us …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2014
201406475 — Commissioner for Ethical Standards in Public Life in …
Mr C had complained to a local authority about their services. When they did not investigate his complaint he asked a councillor to review the matter. The councillor felt that this would go beyond his remit and declined to become involved. Mr C complained about the councillor to the Commissioner …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Feb 2016
201404550 — Scottish Qualifications Authority
Mr C's daughter appealed to the Scottish Qualifications Authority (SQA) about her results in two subjects. Her appeals were not upheld. Mr C complained on behalf of his daughter to the SQA about the procedures they had followed and that they had not examined apparent administrative errors in the recording …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Mar 2016
201506127 — Crown Office and Procurator Fiscal Service
Mr C complained about a number of actions of the Crown Office and Procurator Fiscal Service (COPFS). Most were beyond our jurisdiction but Mr C also complained about how COPFS had responded to his complaint. We considered that, in their response, COPFS had addressed the issues Mr C complained of, …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
May 2016
201806670 — The Water Industry Commission for Scotland
Mr C complained that the Water Industry Commission for Scotland (WICS) failed to take reasonable or appropriate action in respect of the concerns he raised about a water provider. We found that WICS did not handle Mr C's concerns in line with their Policy for Licence Contraventions. We considered that …
SPSO (Scottish Public Se…
Water
Upheld
Mar 2020
25-007-696 — London Borough of Camden
Summary: We upheld Miss X’s complaint about delays in the children’s statutory complaints process. The Council agreed to resolve the complaint early by paying Miss X a symbolic remedy to recognise her injustice and complete its investigation.
LGO (Local Government & …
Children S Care Services
Upheld
Dec 2025
21-005-954 — Lancashire County Council
Summary: Ms X complained about the actions of the Council and the Enforcement Agency after she received a penalty charge notice. The Council was at fault when it and the Enforcement Agency failed to inform Ms X of her appeal rights or how to escalate her complaint. The Council has …
LGO (Local Government & …
Transport And Highways
Upheld
Jan 2022
21-004-999 — Bristol City Council
Summary: The Ombudsman found fault by the Council on Mrs Q’s complaint of it failing to act against a neighbouring allotment tenant after upholding her complaint and failing to respond to her correspondence. It failed to keep proper records, could not show it did what it said it would do, …
LGO (Local Government & …
Other Categories
Upheld
Feb 2022
21-014-433 — London Borough of Lewisham
Summary: The Council failed to provide evidence of compliance with a remedy it previously agreed with the Ombudsman. In the original complaint, we found the Council failed to investigate Mr B’s complaint The Council agreed to make a financial payment to recognise the impact of its fault. The Council was …
LGO (Local Government & …
Housing
Upheld
Feb 2022
21-009-815 — Tameside Metropolitan Borough Council
Summary: Mrs Y complains about the conduct of the Council’s presenting officer before a school admission appeal hearing. She complains the Council failed to respond to her complaint. We have upheld Mrs Y’s complaint that the Council has failed to respond to her complaint. This caused Mrs Y uncertainty. To …
LGO (Local Government & …
Education
Upheld
Mar 2022
21-004-840 — London Borough of Waltham Forest
Summary: Mr X complained he was excluded from the Council’s Rapid Employment Service. He also complained the Council’s investigation of his complaint was flawed. The Ombudsman found no evidence the Council excluded Mr X from its service. The Ombudsman did find fault in the Council’s record keeping and in the …
LGO (Local Government & …
Other Categories
Upheld
Apr 2022
21-013-440 — Bristol City Council
Summary: Miss X complains the Council failed to make a formal record of, or disclose, its reasons for refusing some applications for Community Infrastructure Levy and Section 106 funds. We have found fault with the Council’s actions. The Council has agreed to apologise to Miss X and make changes to …
LGO (Local Government & …
Other Categories
Upheld
Apr 2022
21-000-037 — Sheffield City Council
Summary: The Ombudsman found fault by the Council on Ms J’s complaint about its failure to take enforcement action against noisy neighbours. It failed to provide us with complete records, show it considered and reached a decision on her acoustic report, and failed to show whether officers properly considered and …
LGO (Local Government & …
Environment And Regulation
Upheld
Apr 2022
21-001-564 — London Borough of Haringey
Summary: Ms B complained about the delay in dealing with her complaint about children’s services. We found the Council delayed in completing the process and has not yet sent Ms B the reports in an accessible format. We have asked the Council to pay her £150 and send her the …
LGO (Local Government & …
Children S Care Services
Upheld
May 2022
21-008-100 — North Western Inshore Fisheries & Conservation Authority
Summary: Mr B says the Authority’s decision to prosecute his company was flawed at the outset; we find no fault in that action. We find the Authority failed to acknowledge Mr B’s correspondence, and it could have responded and managed Mr B’s expectations at that stage, which might have avoided …
LGO (Local Government & …
Other Categories
Upheld
Jun 2022
22-001-554 — Wigan Metropolitan Borough Council
Summary: The Council was at fault when it did not consider Mrs X’s complaints under the statutory children’s complaints procedures. The Council also delayed or failed to provide a substantive response to many of Mrs X’s complaints. It has agreed to apologise, pay her £250 and make service improvements to …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
21-006-247 — Bolton Metropolitan Borough Council
Summary: Mr X complains that the Council did not tell Mr P that his direct payment account was in arrears, and arrears were building up over years. Mr X says this caused Mr P unnecessary distress. We find the Council at fault, and this fault caused Mr P and Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-002-492 — London Borough of Haringey
Summary: We will not investigate this complaint about the Council’s complaints team failing to respond to the complainant’s request for information. This is because the Council’s complaints team has now apologised for its failure to respond but confirmed another team did respond to the complainant’s concerns. So, there is nothing …
LGO (Local Government & …
Environment And Regulation
Aug 2022
22-003-365 — Worcestershire County Council
Summary: Mrs X complained the Council delayed considering her complaint at stage three of the children’s statutory complaints procedure. She says the delay has caused frustration and distress. The Council was at fault when it did not hold the stage three panel within the statutory timescales. The Council has agreed …
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2022
21-013-725 — Warrington Council
Summary: We found fault on Mr J’s complaint about how the Council responded to his reports of his property flooding and to his formal complaint. The Council communicated poorly with him but took steps to improve communication in the future. The Council failed to keep proper records. The agreed action …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-006-804 — East Riding of Yorkshire Council
Summary: We have upheld this complaint because the Council delayed consideration of a complaint at stage two of the children’s statutory complaints procedure The Council has now agreed to resolve the complaint by providing an appropriate remedy for the injustice caused to the complainant by its delay.
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2022
22-000-208 — London Borough of Camden
Summary: Miss X complains the Council unfairly placed her on its Unreasonable Complainant Behaviour register. Although we have not seen any evidence of fault in the Council’s decision to place Miss X on the register, we cannot see that it considered an appeal from Miss X in line with its …
LGO (Local Government & …
Other Categories
Upheld
Sep 2022
21-011-711d — CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-711c — Woking and Sam Beare Hospice and Wellbeing Care …
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
22-000-253 — East Riding of Yorkshire Council
Summary: Miss B complained about excessive delay by the Council in completing the statutory complaints process and its failure to implement the agreed recommendations. We found fault in the Council’s failure to implement the recommendations in full and its poor communication with Miss B in respect of these actions. The …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
22-008-036 — Reading Borough Council
Summary: We uphold Ms X’s complaint that the Council failed to consider his complaint within its children statutory complaints’ procedure. The Council has agreed to do so without further delay.
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
21-018-132 — Surrey County Council
Summary: Mrs X complains the Council has not completed some of the agreed remedy actions after it upheld her complaints following an investigation under the children’s statutory complaints procedure. The Council is at fault. It has not completed some of the actions agreed. There was also poor record keeping which …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
21-017-125 — Surrey County Council
Summary: Mrs X complained that the Council failed to deal properly with her complaint under the three-stage children's social care complaints procedure. The complaint was about failure to respond adequately to her requests for extra social care support for her disabled son. The children’s social care complaint investigation identified failings …
LGO (Local Government & …
Children S Care Services
Not Upheld
Oct 2022
22-005-982 — Leeds City Council
Summary: Miss B complained about the Council’s action in respect of council tax involving her business. She said the Council delayed in responding, then gave her incorrect advice, proceeded with recovery action even though she had made a complaint and delayed in responding to her complaint. We found fault with …
LGO (Local Government & …
Benefits And Tax
Upheld
Nov 2022
22-000-598 — London Borough of Havering
Summary: Ms J complained the Council caused delays in deciding her housing register application and failed to respond to her complaint as set out in its policy. She also said its housing service officers customer service was poor. We found the Council’s customer service was poor, and there were delays …
LGO (Local Government & …
Housing
Upheld
Dec 2022
23-015-707 — Coventry City Council
Summary: We have upheld this complaint about delay in the children’s statutory complaints procedure. This is because the Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused.
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2024
24-008-972 — Bolton Metropolitan Borough Council
Summary: Mrs K complained the Council did not cut the grass in a cemetery, causing it to become overgrown and inaccessible. She also complains the Council did not respond to her complaint about this. We consider the fact the Council did not cut the grass to be service failure, and …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
24-004-402 — Woking Borough Council
Summary: Mr X complained the Council unfairly rejected his application to hold a circus on its land and poor complaint handling. We found the Council was at fault because it did not respond to his complaint or several enquiries by us. This caused Mr X avoidable distress, time and trouble. …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
24-011-008 — Newcastle upon Tyne City Council
Summary: Mr X complained about how the Council delivered support to his son. We have found that the Council was at fault, because it has not yet dealt with Mr X’s complaint properly. It will now do so. It has also agreed to make a symbolic payment to Mr X …
LGO (Local Government & …
Children S Care Services
Upheld
May 2025
25-002-083 — London Borough of Lewisham
Summary: Miss X complained the Council failed to deliver services to her child. She also complained about its complaint handling. We found the Council was at fault. Miss X did not have the opportunity to have her complaint properly considered via the children’s statutory complaints procedure. The Council will apologise …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2025
24-022-089 — South Tyneside Metropolitan Borough Council
Summary: We uphold this complaint that the Council used another process rather than the statutory procedure for complaints about children’s services to respond to Mrs X’s complaint. The Council has agreed to resolve the matter by providing a suitable remedy for the injustice caused to Mrs X.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-016-941 — Bury Metropolitan Borough Council
Summary: Mr B complained the Council has repeatedly left his bins blocking access to his driveway after collections, despite assuring him this would be resolved. The Council was at fault. It continued to leave Mr B’s bins blocking his driveway, after agreeing to leave them elsewhere. It also demonstrated poor …
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2025
24-012-224 — Thanet District Council
Summary: Mrs B complained the Council failed to adequately investigate her complaint of an officer’s conflict of interest. We find the Council at fault for a delay in completing its investigation and failing to keep investigation records. This has caused Mrs B frustration, distress and uncertainty. The council has agreed …
LGO (Local Government & …
Planning
Upheld
Aug 2025
24-020-123 — Milton Keynes Council
Summary: We have upheld Miss X’s complaint because the Council delayed responding to her complaint and considered the complaint under the incorrect procedure. The Council has agreed to provide a proportionate remedy to Miss X.
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2025
201003128 — Glasgow City Council
Mr C and Ms D were involved in extra-curricular activities at their son’s school. They were uncomfortable with the actions of another parent, who they felt was promoting unacceptable racist and sexist views among the school community. Ms D, in particular, felt the parent was using bullying behaviours to make …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2011
201002957 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C suffers from Graves or Thyroid Eye Disease which is a complex and devastating condition. She complained that after 2007 her care and treatment was poor and likened it to a ‘production line’. She alleged that she had been examined and discharged without comment from either medical or nursing …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2011
201100439 — Scottish Prison Service
Mr C, who is a prisoner, complained following a decision taken by the prison to refuse certain items of property he requested to have in use. Mr C said the decision taken by the prison was unreasonable and he said his request had not been considered in line with the …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Nov 2011
201103592 — Grampian NHS Board
Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2012
201200078 — Dumfries and Galloway Housing Partnership
Mr C, who is a councillor, wrote to the housing partnership on behalf of a tenant (Mr A) who was unhappy with their handling of his complaint about the way he was treated by a staff member. Mr C complained that he was given inaccurate information about the partnership's complaints …
SPSO (Scottish Public Se…
Local Government
Upheld
Sep 2012
201103657 — Fife Council
Mr and Mrs C complained about comments that they said a council officer had made about Mr C. The council initially dealt with the complaint through the statutory social work complaints procedure and upheld it. However, after taking legal advice the council decided that the complaint had been outwith the …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2012
201103632 — Perth and Kinross Council
Mr C acts as guardian and carer for his disabled adult son. He complained that the council did not properly investigate a complaint that he made on behalf of his son. He also said that they did not provide advice about the social work complaints procedure, by failing to tell …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2012
201202059 — Forth Valley NHS Board
Mr C, who is a prisoner, complained to the board about the medication decisions taken by his prison health centre. Mr C was not satisfied with their reply, which he felt had not addressed his concerns, and so he sent them a follow-up letter. However, the board sent it back …
SPSO (Scottish Public Se…
Health
Nov 2012
201103742 — Tayside NHS Board
Ms C complained about the care and treatment she received from a hospital. She outlined eight specific areas of concern, including communication, standard of care, waiting times, lack of after care and competence of staff. She said that she initially went to the hospital with symptoms of bowel disease, but …
SPSO (Scottish Public Se…
Health
Not Upheld
Nov 2012
201103618 — Fife Council
Mr C raised a complaint about the council's handling of a cement batching plant at a quarry. In particular, Mr C complained that the cement batching plant had changed from being an ancillary operation at the quarry to a mainstream operation and that the council had failed to require the …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2012