Delayed patient infection risk notification
Inconsistent guidance leading to delayed notification of patients about infection risks from surgery (e.g., Mycobacterium Chimaera).
151 items
9 sources
3 inquiries
Source spread
Where this theme appears
Delayed patient infection risk notification has been flagged across 9 independent accountability sources:
7 inquiry recs
51 PFD reports
10 committee recs
5 CQC actions
7 PPO recs
6 IMB recs
1 Scottish FAI
48 PHSO decisions
16 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 (7)
R41 — Laboratory specimen processing
Recommendation: Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment.
Gov response: Section 3.2 of the Scottish Government's response highlights that NHS board antimicrobial management teams (AMTs) drive comprehensive approaches to education on antimicrobial stewardship for clinical staff and promote application of antimicrobial policies. Section 4.2 details …
Accepted
R37 — CDI senior assessment and treatment
Recommendation: Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy for CDI is commenced timeously.
Gov response: Section 4.1 of the Scottish Government's response acknowledges that recommendation 37 addresses delays in diagnosing and treating C. diff infection. Section 2.1 details that Scotland's Health Protection Network published C. diff guidance, revised in 2014, …
Accepted
IBI-8a — Pre-1996 Transfusion Testing
Recommendation: When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.
Gov response: Implemented across all four nations. Healthcare providers directed to offer Hepatitis C testing to patients who received transfusions before 1996.
Accepted
R65 — Isolation for infectious diarrhoea
Recommendation: Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICPs), which are basic measures to reduce the risk of germ transmission. Among the 10 SICPs is "Patient placement in wards and …
Accepted
R63 — Effective CDI patient isolation
Recommendation: Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.
Gov response: Section 3.1 of the Scottish Government's response addresses patient isolation through the requirement for all planned new-build hospitals to provide 100% single-room accommodation, and refurbished builds at least 50%. This measure significantly reduces the risk …
Accepted
IR2-2 — Eligibility Conditions for Infected Persons
Recommendation: I recommend that the conditions of eligibility for admission of relevant infected persons to the scheme should be that: a) they have been diagnosed as being infected with one or more of HCV (including natural clearers who have suffered loss), …
Gov response: In accordance with recommendations 1 and 2 of the Second Interim Report, the Government is clear that both those who have been infected and affected by this scandal are eligible for compensation and is compensating …
Accepted
PENROSE-1 — HCV Testing for Pre-1991 Transfusion Recipients
Recommendation: The Scottish Government takes all reasonable steps to offer an HCV test to everyone in Scotland who had a blood transfusion before September 1991 and who has not been tested for HCV.
Gov response: No formal government response published. Scottish Government established Short-Life Working Group with Health Protection Scotland and Scottish National Blood Transfusion Service to implement testing programme.
Accepted
PFD Reports (51) — showing 50 strongest matches
Craig White
Concerns: Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.
Overdue
Afifa Qaisar
Concerns: Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Overdue
Robert Jones
Concerns: CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Response: The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will …
Responded
Jackson Chadd
Concerns: Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Response (Frimley Park Hospital): The Hospital updated sepsis guidelines to include tachycardia, changed practices to fast track children with PEWS scores of less than 4 to the Paediatric Assessment Unit, and now requires blood …
Response (Royal College of Paediatrics Child Health): The RCPCH refers to existing guidance, standards and reports regarding supervision and training and notes their current review of standards to encourage higher levels of consultant supervision.
Overdue
Shannon Gee
Concerns: Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.
Overdue
George Taylor
Concerns: A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.
Response (Department of Health): The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. …
Responded
Mary Marshall
Concerns: A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.
Response (Department of Health1): NHS England will work with partners to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including GDH testing. NHS England will …
Responded
James Bateley
Concerns: Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.
Response (Coastal West Sussex Clinical Commissioning Group): The CCG contacted the Deputy Chief Nurse, Sussex Community NHS Trust to investigate the delay in ordering dressings, and assurance was obtained from the Pharmacy that there was no delay …
Response (Sussex Community NHS Trust): Immediate actions taken include meeting with the CCG, implementing a 'Stock box/First Dressing' system, and implementing an escalation process for delays in dressings supply. Longer-term actions are being discussed with …
Responded
Sally Ellison
Concerns: There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.
Response (NHS Wales): NHS Wales, through the Pathology Clinical Programme Group, has reviewed the process for requesting urgent samples from primary care and is distributing a memorandum to GPs and Practice Managers with …
Responded
Alan Stead
Concerns: Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Response (Care UK): Care UK implemented a training program for nurses and HCAs in phlebotomy at HMP Dovegate, completed in March 2016, to ensure timely blood tests. The Governance team also shared learning …
Responded
Gordon Arthur
Concerns: The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.
Response (Salford Royal NHS Trust): Salford Royal NHS Trust reviewed policies and confirmed existing protocols for rapid notification of unsuspected pathology. These protocols have been disseminated by email and discussed at the Orthopaedic clinical governance …
Responded
Raymond Edwards
Concerns: A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Response: The University Health Board developed BCUHB Procedure MD23 to mitigate risks due to failure to act on diagnostic results, based on NPSA 16 guidance, and approved at the end of …
Responded
Patricia Parker
Concerns: Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.
Overdue
Tomas Kelly
Concerns: Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.
Response (Joint Committee on Vacccination and Immunisation): The JCVI is currently reviewing its advice on varicella vaccination and will consider including children with Down’s syndrome in the list of high-risk groups during meetings in 2018.
Responded
Edna Collett
Concerns: A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.
Overdue
Dylan Hill
Concerns: A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.
Response (Food Standards Agency): The FSA will be meeting with other government departments and organisations to discuss tackling food allergy issues, and welcomes the Coroner's contribution to these discussions; will also be placing more …
Response (Barnsley Hospital NHS Trust): The Trust has reviewed and updated its anaphylaxis draft protocol and included a referral form to inform Trading Standards of cases of anaphylactic reaction from commercial premises. The draft protocol …
Response (Department of Health): The FSA will set up a cross-government discussion to consider the reporting of non-fatal anaphylaxis, while Barnsley and Sheffield are exploring the development of local notification systems and considering ways …
Responded
Tom Cribley
Concerns: Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Overdue
Peter Knight
Concerns: The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.
Response (The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust): The Trust revised its Transfer of Patients Policy, ratified on May 7th, and delivered "Transferring the Critically Ill Patient" training including a decision to not transfer patients on Hi Flo …
Responded
Prabhaker Kapoor
Concerns: Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause Analysis report.
Response (Birmingham Hospitals NHS Trust): The Trust has updated its Moodle training package with SLT input to reflect standard operating procedures for dysphagia and 'nil by mouth' patients, reviewed standard operating procedures, developed 'preventing harm' …
Responded
Peter Smith
Concerns: Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery impossible and contributed to the patient's death.
Response (Shrewsbury and Telford NHS Trust): Response from. UNMH
Response (Response from. UNMH): University Hospitals of North Midlands NHS Trust states that Shrewsbury and Telford Hospital NHS Trust, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, has produced a Standard …
Responded
Ibiyemi Ereoah
Concerns: Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.
Overdue
Brenda Elmer
Concerns: Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to share Listeria isolates, hindering timely outbreak identification.
Response (UK Health Security Agency): PHE implemented an Incident Management Team following listeria cases, inspected the sandwich manufacturer, and wrote to national microbiological standards to update the SOP for identification of Listeria. The updated SOP …
Responded
Joan Sanderson
Concerns: The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Response (GM Health and Social Care Partnership and Healthcare Safety Investigation Branchwillbe): The GM Health and Social Care Partnership notes that the Regulation 28 letter has also been sent to HSIB and will leave it to the named respondent to address the …
Overdue
Leslie Harris
Concerns: The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.
Response (NHS England): NHS England contributed to updated Public Health England guidance published January 2021, strengthening messaging and providing further clarity on care pathways, testing, and exposure regarding COVID-19 in healthcare settings. The …
Response (UK Health Security Agency): The UK Health Security Agency (formerly Public Health England) updated its guidance several times during the pandemic and will further review it to tighten wording and prevent misinterpretation regarding COVID-19 …
Responded
Norma Bradbury
Concerns: A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.
Overdue
Thiago Araujo
Concerns: The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Response (St Pancras Hospital): The Trust has implemented an additional recommendation that discharge of Crisis Team service users due to non-engagement must be discussed in a multidisciplinary meeting with senior overview, and clearly communicated …
Response (Royal Mail): Royal Mail asserts that their processes for handling restricted and prohibited items are adequate and appropriate, given the legal restrictions on interfering with postal packets. They state that they do …
Response (Metropolitan Police Service): The MPS is developing a Suicide Prevention Policy Document and Toolkit. An investigative standards document is also under development as guidance for police first responders.
Response (Dept. of Health and Social Care): The Department of Health and Social Care describes actions taken to limit the availability of chemicals used in suicides, including working with a chemical supplier to identify suppliers on online …
Response (Home Office): The Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions …
Overdue
Nicholas Winterton
Concerns: The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.
Response (UK Health Security Agency): PHE will update risk estimates for Mycobacterium chimaera infection and publish them by September 2021, cascading the information to healthcare professionals through clinical networks; they will forward the request to …
Overdue
Roger Phelps
Concerns: Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID wards, a risk potentially unresolved in other trusts.
Overdue
Christopher Collinson
Concerns: A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.
Response (Queen Elizabeth Hospital): The Trust has rolled out its in-house electronic system, PICS, to Birmingham Heartland’s Hospital AMU to provide a paper-free electronic patient record. However, they will not be introducing a secondary …
Responded
Natasha Adams
Concerns: A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): The Trust completed an audit of compliance against the Care Programme Approach (CPA) on 12 May 2022, finding that 80% of patients reviewed had received a formal CPA review.
Responded
Trevor Reynolds
Concerns: The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.
Response (Betsi Cadwaladr University Health Board): The Health Board has made all oncology and haematology staff aware of the SOP for escalating urgent radiology results and added it to the induction checklist and secretarial meetings. Audits …
Overdue
Angela Maguire
Concerns: The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative care discussions.
Response (NHS England): NHS England is actively implementing the NHS Long Term Plan to establish Imaging Networks across England by 2023, aiming for 70% of networks to reach a 'Maturing' level by 2024/5. …
Overdue
Jack Hurn
Concerns: The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist consultations, despite available national and regional pathways.
Response (NHS Worcestershire Acute Hospital): Worcestershire Acute Hospitals NHS Trust has reopened its internal review into the death of Jack Hurn, reinstated the serious incident record, and restructured its central patient safety team. The Trust …
Responded
Rita Flynn
Concerns: A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.
Response (The Royal Wolverhampton): The Royal Wolverhampton NHS Trust has incorporated a section for documenting investigations and results into the ED clerking document. They have also agreed to include training on reviewing blood results …
Responded
Sara Jones
Concerns: A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical lack of protocol for radiology report delivery.
Response (University Hospitals of North Midlands): UHNM has recruited one additional consultant to the trauma rota, with negotiations underway with three more, to fill the Monday-Friday rota by August 2023. Approval for a business case to …
Response (Betsi Cadwaladr University Health Board): BCUHB has established a process to email radiology reports and confirm receipt by telephone if a patient leaves the emergency department without a report. This process is being included in …
Responded
Akash Bhudia
Concerns: Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.
Response (Medica Group): Medica have edited their Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers, and this has been circulated …
Responded
Helen Coogan
Concerns: Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
Response (Ritchie Street Group Practice): The practice discussed the case at a partners meeting and raised a significant event to discuss with the wider team, but concluded that no further action could be taken because …
Responded
Maria Shafighian
Concerns: An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.
Response (Aneurin Bevan University Health Board): To improve the internal referral process for the ENT department, referrals will be sent straight to the Central Registration department for upload and electronic triage, mirroring the GP process; a …
Responded
Clinton Fear
Concerns: Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from prior procedures.
Overdue
Kai Takagi
Concerns: Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.
Response (NHS England): NHS England highlights existing national guidance and standards for following up on test results after discharge and refers to their urgent and emergency care recovery plan, noting the responsibility of …
Overdue
Terence Hines
Concerns: Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.
Response (Worcestershire Acute Hospitals): The Trust updated its Isolation Policy to require a Red clean for every known case of MRSA and distributed a "lessons learned" poster to wards to highlight learning from the …
Responded
Ethel Reed
Concerns: Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. Additionally, electronic patient records failed to track author changes on discharge letters, risking miscommunication.
Response (NHS England): The Trust have informed the supplier of the issue with Lorenzo, and they are working on a solution which displays the identification of the author of the Immediate Discharge Summary …
Response (CQC): The trust has sent out communications to reinforce the process that needs to be followed when completing Immediate Discharge Summaries (IDS) for patients using the Trust’s Electronic Patient Record (EPR) …
Response (Humber Health Partnership Hull Royal Infirmary): The hospital is planning to consolidate clinical notes into the clinical data capture (CDC) forms in Lorenzo, instead of IDS templates, in order to improve data capture. This piece of …
Overdue
David Curry
Concerns: A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre capacity, increasing the patient's sepsis risk, leading to the patient seeking private care and subsequently dying from sepsis.
Response (Department of Health and Social Care): The Department of Health and Social Care addresses concerns about waiting lists and risks and highlights regional support to challenged Trusts, including the opening of a new orthopaedic centre and …
Responded
Gillian Stokes
Concerns: Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.
Response (Department of Health and Social Care): The DHSC will explore with MHRA and NHSE raising awareness of angiosarcoma following radiation with patients and clinicians. They note that surveillance guidance for angiosarcoma may do more harm than …
Response (Royal College of Nursing): The RCN supports the coroner's concerns regarding lack of guidance and pathways for radiation induced sarcoma, implants, and the current surveillance period. However, as a professional body, they do not …
Response (Ashford and St Peters Hospitals NHS Foundation Trust): Ashford and St Peters Hospitals NHS Foundation Trust is developing a Standard Operating Procedure (SOP) for the Breast One Stop Shop Clinic that will outline guidelines for patient follow-up care, …
Response (Royal College of Radiologists): The RCR has tasked the authors of their 'Guidance on screening and symptomatic breast imaging' to consider the coroner's concerns during the current review and ensure all modalities are considered.
Responded
Malcolm Taylor
Concerns: A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk of future deaths.
Response (Department of Health and Social Care): DHSC acknowledges concerns about mental health bed availability and highlights ongoing efforts to improve community support and patient flow, including the NHS community mental health framework. They also reference published …
Responded
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Response (NHS England): NHS England detailed several actions taken to address the coroner's concerns, including: implementing a 'Complex Call' process to ensure clinicians assist health advisors with medication/medical related triaging, and providing 'Hot …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the coroner's concerns regarding the NHS Pathways system and patient information sharing, noting that NHS England is responding to the specific concerns …
Overdue
Khadija Kerri
Concerns: The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and treating a patient's fractures.
Response (Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust): The Trust has reviewed and scheduled for approval a revised Failsafe Alert for Radiological Findings (Communication Protocol) which will be uploaded to the Trust's intranet. A key amendment addresses communication …
Responded
Gareth Tatchell
Concerns: Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
Response (Bwrdd Lechyd Prifsgol Bae Abertawe): The Health Board has secured locum cover for radiology for 12 months commencing in October 2025 and the data issue has been remedied with the information now captured on our …
Response (Pennine Care NHS Foundation Trust): Although current monitoring requirements for clozapine remain unchanged, the Trust will circulate emerging scientific literature regarding less frequent blood count monitoring to all prescribers and pharmacists to increase scrutiny of …
Responded
Leslie Thompson
Concerns: A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital environment.
Response (Department of Health and Social Care): The Department of Health and Social Care is strengthening partnerships between the NHS and social care and every acute hospital has access to a care transfer hub operating seven days …
Responded
Nicola Mulliss
Concerns: A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Response (Newcastle upon Tyne Hospitals NHS Foundation Trust): The Trust will strengthen pathways to ensure appropriate cultures are undertaken in a timely manner when a patient is suspected of having an infection, including wound swabs, and that, where …
Responded
Committee Recommendations (10)
#8 — Identifying and contacting all high-risk individuals after data breach remains difficult.
Recommendation: We asked the Department how it obtained assurance that those put at the highest risk from the data breach were identified and contacted.14 The Department told us that it undertook a risk assessment almost immediately after the breach was discovered, …
Gov response: The government agrees with the Committee’s recommendation. vaccine availability outlines a strategic framework for cross-sector action. VMD is continuing cross-sector engagement to identify ways to improve supply and enable future innovation (involving government, pharmaceutical manufacturers, …
Accepted
#23 —
Recommendation: The Department told us that 429 asylum seekers had been tested for COVID-19, 122 of whom had tested positive.63 In its letter to us after our evidence session, the Department further explained that of those that had tested positive, 29 …
Not Addressed
#19 —
Recommendation: We asked the Department about specific examples where there had been issues with its engagement with local stakeholders. At the end of August 2020, the Department moved asylum seekers, 47 of whom had tested positive for COVID-19, from the Stone …
Gov response: 1.2 There are clear and established mechanisms for national and local engagement between the Home Office (the department) and its stakeholders and partners. UK Visas and Immigration (UKVI) has dedicated MP account management teams. There …
Not Addressed
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Under Consideration
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#16 —
Recommendation: As part of its new cancer plan, the Government should include a plan for how to better align the technology appraisals carried out by NICE with the regulatory process applied by the MHRA, in order to reduce the delay between …
Gov response: The Government is committed to supporting timely access for NHS patients to clinically and cost-effective new drugs. The 2019 Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), agreed with industry, commits the National Institute …
Accepted
#15 —
Recommendation: For patients with limited treatment options the approval of a new drug or therapy can make a significant difference even when the survival benefit is only months. Despite the effectiveness of the Medicines and Healthcare products Regulatory Agency’s regulatory process, …
Gov response: The Government is committed to supporting timely access for NHS patients to clinically and cost-effective new drugs. The 2019 Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), agreed with industry, commits the National Institute …
Under Consideration
#10 —
Recommendation: The vaccine programme still has some issues to address. In England, 2.98 million adults were still unvaccinated at the end of May 2022. Analysis by UKHSA has confirmed that full and booster vaccination reduces the risk of someone falling seriously …
Gov response: 1. PAC conclusion: Nearly 3 million adults in England remain unvaccinated and are therefore at greater risk of becoming hospitalised or dying because of COVID-19 than if they were vaccinated. 2 1: PAC recommendation: Both …
Not Accepted
CQC Inspection Actions (5)
Alde House
The registered persons failed to notify the Commission without delay of incidents which occurred whilst services were provided in the carrying on of the regulated activity, or as a consequence of the carrying on of the regulated activity. Such incidents …
Must Do
Alde House
The registered persons failed to notify the Commission without delay of the death of service users whilst services were being provided in the carrying on of the regulated activity.
Must Do
Suffolk House
The provider failed to ensure people were protected from the spread of infection and systems in place did not ensure risks were managed safely.
Must Do
Burrswood Health and Wellbeing
The registered provider must establish robust arrangements to ensure that a statutory notification is promptly submitted to the Care Quality Commission.
Must Do
Newland House
We recommend the registered manager and provider familiarise themselves with the circumstances when they need to make notifications to CQC by consulting the relevant regulations.
Should Do
PPO Death in Custody Recommendations (7)
The Director and Head of Healthcare
The Director and Head of Healthcare should review the process in place for preparing applications for early release on compassionate grounds to ensure that the necessary evidence, including a specialist medical report, is obtained as quickly as possible.
The Head of Healthcare
ensure that the results of hospital investigations are promptly communicated to prisoners.
The Head of Healthcare
The Head of Healthcare should review the current vaccinations process to ensure that if a patient is unavailable, a further appointment is offered.
The Head of Healthcare at Stafford
The Head of Healthcare at Stafford should ensure that where prisoners are already under the care of a hospital consultant when they arrive, staff: • make hospital referrals promptly; • include all relevant information about the stage of treatment and …
The Head of Healthcare
The Head of Healthcare should ensure that prisoners returning to Bristol following a temporary absence are offered a medical review if they meet the criteria set out in PSI 07/2015.
The Head of Healthcare
ensuring requests for clinical investigations, such as requests for chest X-rays, are actioned promptly
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should work in conjunction with Royal Stoke University Hospital to ensure there is a robust and efficient system for receipt of histology and other laboratory results, and ensure that this information is promptly relayed to patients.
IMB Recommendations (6)
Gartree (2021)
Will the Minister explain the reasons for the delay in rolling out booster Covid-19 vaccine in Gartree (albeit that the Board has been advised that vaccinations were rolled out as per PHE and NHSE guidelines except where prisoners were unable to have vaccinations because they had tested positive for Covid-19 within the previous 28 days)? It has been acknowledged that …
Ministry of Justice
Preston (2021)
Will the Minister review the current guidelines and ensure that all personnel within the prison are vaccinated irrespective of the guidelines for the general public (see section 3.1)?
Ministry of Justice
Nottingham (2021)
The inability of the system to ensure that prisoners have a second vaccine appointment on release needs to be addressed (6.1).
HMPPS
Tinsley House IRC (2020)
to reconsider its current policy of not Covid-19 testing detainees on arrival at Tinsley House STHF, or thereafter during their period of detention.
Home Office
Durham (2023)
What plans will be put in place to achieve an improved and sustained delivery of “secondary health screening within 7 days”? (6.2.3)
Governor / Director
Humber (2020)
The number of Patient Advice and Liaison Service (PALS) submissions which are not responded to within the stipulated 10 days is of concern to the Board. There was a total of 530 PALS submissions in 2020, 264 (50%) of which were not replied to within the specified timescale. Following a freedom of information (FOI) request, the healthcare provider - CHCP …
Governor / Director
PHSO Casework Decisions (48)
P-002750 — Maidstone and Tunbridge Wells NHS Trust
Mr R complains the Trust did not correctly monitor his cystic fibrosis related infection and delayed putting in place an antibiotic treatment plan between December 2022 and February 2023.
NHS in England
Jul 2024
P-003770 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs C complained about the care and treatment of her adult son when he was admitted to hospital in November 2022. She complains doctors failed to give him antibiotics in a timely way even though he was admitted with a known infection.
NHS in England
Upheld
Aug 2025
P-001958 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr A complains the Trust did not start compulsory COVID-19 testing for asymptomatic staff as soon as it should have. He complains his father caught COVID-19 while he was an inpatient at the Trust.
NHS in England
Not Upheld
Apr 2023
P-002002 — University Hospitals Birmingham NHS Foundation Trust
Mr Y complains about the care the Trust gave to his mother. He complains Mrs Y got a second infection while an inpatient at the Trust and staff did not tell him. He also complains it did not reply to his complaint.
NHS in England
May 2023
P-002553 — Stockport NHS Foundation Trust
Mr D complains about the care he had after surgery and that nurses did not clean his wound for two days which led to a severe infection. He also complains the Trust wrongly told him he had cancer.
NHS in England
Apr 2024
P-003085 — An independent provider in the Berkshire area
Mr P complains the Provider missed clear signs and symptoms of his son’s pneumonia which led to sepsis.
NHS in England
Oct 2024
P-003010 — Royal Devon University Healthcare NHS Foundation Trust
Mr E complains that in December 2022 the cardiology team failed to review him and discharged him inappropriately. He says Trust staff exposed him to flu and put him in a bay with no access to hot water. He also says the Trust failed to follow its guidelines as it …
NHS in England
Oct 2024
P-003418 — University College London Hospitals NHS Foundation Trust
Mr W complains his mother was admitted to a ward where patients had COVID-19 and she then caught it. He also complains there was a lack of communication from the Trust and a failure to effectively treat his mother's leg ulcer.
NHS in England
Mar 2025
P-003454 — A practice in the Gloucestershire area
Ms G raised concerns about the care provided by the Practice, as she felt opportunities were missed to diagnose an ongoing infection.
NHS in England
Mar 2025
P-003477 — A practice in the Wiltshire area
Mr O complains the Trust failed to identify multiple fractures and did not give him antibiotics to prevent an infection. He also says the Trust’s communication with his family was poor. Mr O complains the Practice did not identify that his injuries needed further investigation or provide medication to treat …
NHS in England
Apr 2025
P-003788 — Mid Yorkshire Teaching NHS Trust
Ms A complains about the decision to catheterise her son and keep him catheterised, the failure to diagnose a UTI/sepsis sooner and the physiotherapy provided to her son between August and December 2022.
NHS in England
Not Upheld
Aug 2025
P-003768 — Portsmouth Hospitals University NHS Trust
Miss C complains the Trust did not administer her with antibiotics before her baby was born in September 2024. She also says the Trust did not listen to her concerns about jaundice before and shortly after her and her baby were discharged.
NHS in England
Aug 2025
P-003785 — An independent provider in the Sheffield area
Miss H complains about the organisation following hysterectomy surgery in June 2023. She says she had a post-operative haemorrhage, and then had an infection after she was discharged.
NHS in England
Aug 2025
P-004130 — A practice in the Oldham area
Mrs B complains that on 10 and 24 October 2022, the Trust did not take steps to protect her sister from infection when she needed investigations. She says she was undergoing chemotherapy for acute myeloid leukaemia and was at high risk of infection.
NHS in England
Partly Upheld
Oct 2025
P-004401 — East Suffolk and North Essex NHS Foundation Trust
Mrs D says the Trust did not test her husband Mr D for flu when he was admitted to the intensive treatment unit (ITU) in December 2022.
NHS in England
Partly Upheld
Dec 2025
P-001516 — The Royal Wolverhampton NHS Trust
Mrs I complains about the care her father received from the Trust after he was admitted to hospital. She says Trust staff did not correctly follow the cross-infection guidelines which meant her father caught COVID-19 from another patient, and subsequently died.
NHS in England
Aug 2022
P-001695 — The Dudley Group NHS Foundation Trust
Miss I complains about the Trust's care of her grandmother, Mrs E. Miss I complains the Trust wrongly gave Mrs E beta blockers, did not give her antibiotics for her foot at the right time, would not let family go to tests with her and that something went wrong during …
NHS in England
Nov 2022
P-001620 — University Hospitals of North Midlands NHS Trust
Mrs A complains about her mother's, Mrs B's, end of life care saying the Trust did not give the right medication and antibiotics were delayed.
NHS in England
Nov 2022
P-001983 — Hampshire Hospitals NHS Foundation Trust
Ms C complains about the care the Trust gave to her father when he had COVID-19. She also complains about the Trust's communication with the family and for not consulting them about its management plan.
NHS in England
May 2023
P-002439 — Mid and South Essex NHS Foundation Trust
Miss N complains the Trust failed to treat an infection her mother developed after she had surgery in August 2022.
NHS in England
Feb 2024
P-002514 — Milton Keynes University Hospital NHS Foundation Trust
Ms C complains staff delayed diagnosing her father's COVID-19 illness and starting treatment. She also complains the Trust did not give the right treatment.
NHS in England
Mar 2024
P-002565 — The Dudley Group NHS Foundation Trust
Miss R complains about the care and treatment the Trust gave her after a planned caesarean section in November 2021. She says she got an infection and sepsis.
NHS in England
Apr 2024
P-002652 — Stockport NHS Foundation Trust
Mrs E complains the Trust delayed recognising signs of deterioration and symptoms of COVID-19 and delayed her mother’s COVID-19 test. She also complains that staff would not allow the whole family to be at her mother’s bedside in her final hours.
NHS in England
May 2024
P-003445 — Warrington and Halton Hospitals NHS Foundation Trust
Ms R complains about the care and treatment Warrington and Halton NHS Foundation Trust provided to her in August 2023. She says there was no continuity of care during her labour and staff failed to prevent her getting an infection and delayed recognising and treating it.
NHS in England
Mar 2025
P-003506 — West Hertfordshire Teaching Hospitals NHS Trust
Mrs P complains about her late mother’s care and treatment during two hospital admissions, that she was discharged when she was not medically fit and not treated appropriately for an infection.
NHS in England
Apr 2025
P-003638 — University Hospitals of North Midlands NHS Trust
Mr S raised concerns about the Trust’s care of his wife, specifically that it discharged without test results, inadequate monitoring plans, and when it readmitted her to the Trust, it placed her on a ward with other vulnerable patients despite her immunocompromised condition.
NHS in England
Jul 2025
P-004083 — Barts Health NHS Trust
Ms C complains the organisations failed to diagnose her brother's stomach cancer and symptoms of sepsis.
NHS in England
Sep 2025
P-004063 — Portsmouth Hospitals University NHS Trust
Mrs N says the Trust did not correctly diagnose her husband with colitis (inflammation of the colon) caused by C-DIFF (clostridioides difficile is a bacteria that causes infections in the colon) as early as it should have and missed an opportunity to treat him as early as it should have.
NHS in England
Sep 2025
P-004399 — East Suffolk and North Essex NHS Foundation Trust
Mr R complains that East Suffolk and North Essex NHS Foundation Trust failed to detect abnormalities on his chest X-ray from February 2024 and delayed conducting cardiology investigations given what this X-ray showed.
NHS in England
Dec 2025
P-001113 — Northern Lincolnshire and Goole NHS Foundation Trust
Mrs L complained about the Trust’s decision not to provide further treatment to her daughter, Miss A, who had COVID-19. She also complains the Trust would not allow her in the hospital to be with Miss A who had learning difficulties.
NHS in England
Not Upheld
Sep 2021
P-001275 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs I complains about the care and treatment the Trust provided to her mother, Mrs A. This includes concerns about her mother catching COVID-19 while in hospital, a delayed discharge, and her mother being enrolled on a COVID-19 trial.
NHS in England
Partly Upheld
Jan 2022
P-001602 — University Hospitals Bristol and Weston NHS Foundation Trust
Miss A complains her father, Mr A, got sepsis and sadly passed away because he had poor dental treatment from the Trust in February 2019.
NHS in England
Nov 2022
P-001981 — West Hertfordshire Hospitals NHS Trust
Mrs U complains the Trust did not help her husband to shower and he had thrush on his genital area when he was discharged to home. She also complains he caught COVID-19 during a later admission to the Trust and this caused him to have a heart attack and die.
NHS in England
May 2023
P-002051 — Barking, Havering and Redbridge University Hospitals NHS Trust
Ms A complains the Trust delayed doing blood tests and a CT scan for her father.
NHS in England
Jun 2023
P-002966 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs F complains the Trust discharged her mother without the relevant oxygen prescription which resulted in a failed discharge. She complains the Trust did not give her accurate information about her mother’s condition meaning she was not able to follow her mother’s wishes about being at home when she died.
NHS in England
Sep 2024
P-003618 — St George's University Hospitals NHS Foundation Trust
Mrs Y complains the Trust ignored her concerns and delayed identifying an infected wound on her husband’s heel. She also complains her husband was discharged without a catheter.
NHS in England
Upheld
Jun 2025
P-003970 — Barts Health NHS Trust
Mr P complains on behalf of his wife Mrs K about treatment for gallbladder cancer and management of post-procedure infections in 2023. He says the Trust did not provide the best possible treatment.
NHS in England
Sep 2025
P-004178 — Dartford and Gravesham NHS Trust
Mrs A complains about aspects of the care and treatment the Trust provided to her son during its investigation and diagnosis of his cow’s milk protein allergy. Mrs A also complains about her son’s inpatient care when he developed infections in October and December 2023.
NHS in England
Oct 2025
P-004259 — The Royal Wolverhampton NHS Trust
Miss N complains the Trust failed to tell her mother of a cancer diagnosis, and provide adequate pain relief.
NHS in England
Upheld
Nov 2025
P-001319 — The Royal Wolverhampton NHS Trust
Mrs A complained her late father contracted COVID-19 while admitted to the Royal Wolverhampton NHS Trust. She also complained about the Trust's decision to discharge her father, and when he was readmitted she felt the doctors pressured him into agreeing to a ‘Do Not Attempt Resuscitation’ (DNAR) decision.
NHS in England
Not Upheld
Feb 2022
P-001904 — Countess of Chester Hospital NHS Foundation Trust
Ms E complains a previous procedure with her contraceptive coil led her to develop a serious infection and to have life-changing surgery. She also says the Trust ignored her and did not respond to her complaint.
NHS in England
Mar 2023
P-002248 — University Hospitals Sussex NHS Foundation Trust
Mr I complains the Trust failed to diagnose a haematoma in April 2022 and that it did not tell him the results of a COVID-19 test.
NHS in England
Oct 2023
P-002519 — A practice in the Colchester area
Mrs R complains the Practice failed to identify and treat the cause of her mother’s swollen foot and the Ambulance Trust refused to take her to hospital. She complains the Hospital Trust failed to identify her mother’s peripheral arterial disease and she got COVID-19 when she was an inpatient because …
NHS in England
Mar 2024
P-003234 — Tameside and Glossop Integrated Care NHS Foundation Trust
Miss G complains the Trust did not act promptly enough following her partner’s diagnosis in 2017 of Interstitial Lung Disease. She is also concerned the Trust did not notify her partner’s brothers about possible risks to them.
NHS in England
Partly Upheld
Dec 2024
P-003247 — Chesterfield Royal Hospital NHS Foundation Trust
Mr B complains his father got COVID-19 during his admission and staff did not provide treatment. He also complains about the discharge and staff not taking into account his father’s anxiety when communicating treatment plans.
NHS in England
Dec 2024
P-001653 — University Hospitals Coventry and Warwickshire NHS Trust
Mr P complains the Trust did not tell him or his family about his daughter's skin damage when she was discharged. He also complains it failed to refer his daughter to the district nursing team for ongoing care and treatment.
NHS in England
Partly Upheld
Dec 2022
P-002005 — East Kent Hospitals University NHS Foundation Trust
Mrs A complains the Trust outsourced the MRI and CT scans to a third party who reported the results incorrectly. She also complains the Trust missed an opportunity to diagnose Mr A's brain tumour and to give him palliative treatment sooner and it did not give him pain relief.
NHS in England
May 2023
P-002420 — Gateshead Health NHS Foundation Trust
Mr A complains the Trust failed to do a biopsy to check whether a suspicious growth on his partner's lung was cancerous. He also complains the Trust should have done more regular scans so the cancer could be found sooner.
NHS in England
Jan 2024
LGO / SPSO Decisions (16)
NIPSO-202002039 — Western Health and Social Care Trust
A teenage boy waited 18 months to see a consultant after he was diagnosed with arthritis and ruptured ligaments. We asked the Trust to apologise for the failures which caused the delay.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Dec 2023
24-016-431 — City of Bradford Metropolitan District Council
Summary: Mrs X complained the Council incurred delays in considering her application for a Disabled Facilities Grant for her son. She also complained the Council did not properly consider her application. Mrs X said the Council’s actions caused avoidable distress to her son and the family. The Council is at …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2025
20-012-668a — Royal Wolverhampton Hospital NHS Trust (20 012 668a)
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
25-001-856 — London Borough of Barking & Dagenham
We will not investigate Mrs X’s complaint about the Council’s decision to decline an Education, Health and Care Needs Assessment and the delay in providing a decision. This is because it would be reasonable for her to use her right of appeal to a tribunal and there is not sufficient …
LGO (Local Government & …
Education
Jun 2025
NIPSO-201913103 — Belfast Health and Social Care Trust
Our investigation found failings in the care and treatment provided to a cancer patient by the Belfast Health and Social Care Trust.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2023
20-010-783b — Gloucestershire Hospitals NHS Foundation Trust (20 010 783b)
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Health
Upheld
May 2022
20-010-783a — Gloucestershire Hospitals NHS Foundation Trust (20 010 783a)
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Health
Upheld
May 2022
201102400 — Highland NHS Board
Mrs C was admitted to hospital for a gastroscopy (a procedure in which a thin, flexible tube is used to look inside the stomach) under general anaesthetic. She waited in the day room until she was allocated a bed. During this time a member of staff discussed confidential information with …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2012
201004951 — Fife NHS Board
Mrs A was admitted to hospital on numerous occasions in the two years before her death. She had a complex medical history and tested positive for a bacterial infection, Methicillin-resistant Staphylococcus aureus (MRSA), on six occasions during that time. Mrs A's daughter (Mrs C) complained that the board failed to …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2012
201400264 — Highland NHS Board
Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement. When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2015
201708720 — Lothian NHS Board - Acute Division
Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2018
202104334 — Lothian NHS Board - Acute Division
C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2022
202106371 — Lanarkshire NHS Board
C complained that the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2023
202104888 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died. C …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2024
24-011-905 — Sheffield City Council
Summary: We will not investigate Mr X’s complaint about the Council’s refusal to carry out additional work to fix issues, he said were caused by building works the Council completed under a Disabled Facilities Grant. This is because
LGO (Local Government & …
Adult Care Services
Dec 2024
24-009-591 — Somerset Council
Summary: We will not investigate this complaint about delays in completing a disabled facilities grant adaptation. There is no worthwhile outcome achievable by our investigation.
LGO (Local Government & …
Adult Care Services
Dec 2024