Duty of Candour implementation
Identified shortcomings in the practical operation and implementation of duties of candour within healthcare systems.
507 items
12 sources
10 inquiries
Source spread
Where this theme appears
Duty of Candour implementation has been flagged across 12 independent accountability sources:
81 inquiry recs
39 PFD reports
9 committee recs
16 CQC actions
3 ICIBI recs
1 PPO rec
1 PHSO rec
4 IMB recs
3 detention investigation recs
134 PHSO decisions
213 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 (81) — showing 50 strongest matches
BRIS-34 — Ensure patients receive acknowledgement, explanation, and apology when care goes wrong
Recommendation: When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology.
Unknown
BRIS-33 — Establish a duty of candour for all NHS staff regarding adverse events
Recommendation: A duty of candour, meaning a duty to tell a patient if adverse events2 have occurred, must be recognised as owed by all those working in the NHS to patients.
Unknown
F184 — Enforcement by the Care Quality Commission
Recommendation: Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by …
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
F183 — Criminal liability
Recommendation: It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct another in the performance of these statutory duties; To provide …
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" …
Not Accepted
F182 — Statutory duty of openness and transparency
Recommendation: There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory …
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
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F178 — Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and …
Recommendation: The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly …
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
F177 — Openness in public statements
Recommendation: Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
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
F176 — Openness with regulators
Recommendation: Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.
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
F175 — Candour about harm
Recommendation: Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative).
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
F174 — Candour about harm
Recommendation: Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F173 — Principles of openness transparency and candour
Recommendation: Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open …
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
11 — Raise awareness of incident reporting and duty of candour
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with …
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
IHRD-7 — Monitoring Candour Compliance
Recommendation: Trusts should monitor compliance and take disciplinary action against breach.
Gov response: Being Open Framework implemented. Support mechanisms established for staff raising concerns.
Accepted
No update 2+ yrs
IHRD-6 — Support for Candour Compliance
Recommendation: Support and protection should be given to those who properly fulfil their duty of candour.
Gov response: Guidance updated and incorporated into health and social care training and policies.
Accepted
IHRD-5 — Employment Contracts and Duty of Candour
Recommendation: Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
Gov response: Trusts reviewing employment contracts and policies for consistency with duty of candour requirements.
Accepted
No update 2+ yrs
IHRD-4 — Trust Awareness of Duty of Candour
Recommendation: Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of healthcare.
Gov response: Being Open Framework implemented across Trusts. Training provided to staff on duty of candour principles.
Accepted
No update 2+ yrs
IHRD-1 — Statutory Duty of Candour
Recommendation: A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public. (ii) Where death …
Gov response: The Department of Health is taking forward legislation for a statutory duty of candour. Public consultation was held in 2020-2021. Legislation is being prepared as part of broader healthcare reforms.
Accepted
No update 2+ yrs
IBI-5c — Ministerial Duty of Candour
Recommendation: The Government should consider the extent to which Ministers should be subject to a duty beyond their current duty to Parliament under the Ministerial Code.
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
No update 2+ yrs
IBI-5b — Monitoring Non-Statutory Duties
Recommendation: If, on review, the Government considers that it is sufficient to rely on the current non-statutory duties in the Civil Service Code, it should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
No update 2+ yrs
IBI-5a — Civil Service Statutory Duty of Candour
Recommendation: The Government should reconsider whether, in the light of the facts revealed by this Inquiry, it is sufficient to continue to rely on the current non-statutory duties in the Civil Service and Ministerial Codes, coupled with those legal duties which …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
No update 2+ yrs
BRIS-117 — Require contractual stipulation for confidential, non-disciplinary reporting of sentinel events.
Recommendation: There should be a stipulation in every healthcare professional’s contract that sentinel events must be reported, that reporting can be confidential, and that reporting within a specified time period will not attract disciplinary action.
Unknown
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
BRIS-24 — Treat patient consent as an ongoing process, not a single signature event
Recommendation: The process of informing the patient, and obtaining consent to a course of treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient’s signature on a form.
Unknown
14 — Board apologies
Recommendation: We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Gov response: Accepted. Duty of Candour regulations require healthcare providers to be open when things go wrong. NHS Resolution promotes early apology and has clarified that sincere apologies do not constitute admission of liability. Professional Standards Authority …
Accepted
No update 2+ yrs
IHRD-42 — Sharing New Investigation Information
Recommendation: In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
Gov response: Procedures established for sharing new information with families after investigation completion.
Accepted
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes. Patient Advocacy Service being developed.
Accepted
No update 2+ yrs
F180 — Candour about incidents
Recommendation: Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.
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
24 — Involve patients and relatives in incident investigation
Recommendation: We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking …
Gov response: 37. We accept this recommendation. A duty of candour has been introduced. 38. A lack of openness and honesty at Morecambe Bay was a fundamental cause of both the distress of the families, and of …
Accepted
1 — Admit problems and apologise to affected families
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
IHRD-3 — Guidance on Statutory Duty of Candour
Recommendation: Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.
Gov response: Guidance being developed in conjunction with statutory duty of candour legislation.
Accepted
No update 2+ yrs
IHRD-2 — Criminal Liability for Candour Breach
Recommendation: Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Gov response: Under review as part of wider duty of candour and accountability framework development.
Accepted in Part
No update 2+ yrs
IBI-4b — Organisational Culture Change
Recommendation: Cultural Change: That a culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns about patient safety be addressed both by taking the steps set out in (a) above, and also by making leaders accountable …
Gov response: Scotland established an Independent National Whistleblowing Office and introduced Non-Executive Whistleblowing Champions in all Health Boards. Wales enacted the 2020 Act. Northern Ireland is implementing a Being Open Framework.
Accepted in Part
No update 2+ yrs
IBI-4a(v) — Leadership Accountability for Safety
Recommendation: Statutory duty of candour: Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being …
Gov response: Government acknowledges the importance of this principle but notes implementation complexity and potential employment law implications. Exploring whether professional standards and manager regulation could achieve accountability without unintended consequences.
Accepted in Part
No update 2+ yrs
IBI-4a(iv) — Individual Duty of Candour for Leaders
Recommendation: Statutory duty of candour: The statutory duties of candour in England, Scotland, Wales (and Northern Ireland, when introduced) should be extended to cover those individuals in leadership positions in the National Health Service, in particular in executive positions and board …
Gov response: UK Government consultation (November 2024 - February 2025) sought views on whether a professional duty of candour should apply to NHS leaders. Response being prepared considering broader manager regulation proposals.
Accepted in Part
No update 2+ yrs
IBI-4a(iii) — Duty of Candour - England Review
Recommendation: Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.
Gov response: A November 2024 call-for-evidence found inconsistent application of the duty. Government is preparing consultation response with final review report to follow manager regulation consultation conclusions.
Accepted
No update 2+ yrs
IBI-4a(ii) — Duty of Candour - Scotland and Wales Review
Recommendation: Duty of candour: The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it is being in England, to assess how effective its operation has been in practice. Since the duty was …
Gov response: Scotland published updated non-statutory guidance in April 2025 and began stakeholder engagement in June 2025. Wales committed to evaluate the 2020 Act's impact by end of 2026.
Accepted
No update 2+ yrs
IBI-4a(i) — Duty of Candour - Northern Ireland
Recommendation: Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.
Gov response: The Northern Ireland Executive committed to proposing an organisational duty of candour, considering consultation findings and broader Hillsborough Law developments.
Accepted
No update 2+ yrs
DM-17 — Statutory duty of candour for law enforcement
Recommendation: The Panel recommends the creation of a statutory duty of candour, to be owed by all law enforcement agencies to those whom they serve, subject to protection of national security and relevant data protection legislation.
Gov response: The Panel agreed with other independent inquiries, such as Bishop James Jones' report on the experiences of the Hillsborough families, about the need for a duty of candour for public services, including the police. The …
Accepted in Part
No update 2+ yrs
BRIS-115 — Discipline NHS staff who cover up or fail to report sentinel events
Recommendation: Members of staff in the NHS who cover up or do not report a sentinel event may be subject to disciplinary action by their employer or by their professional body.
Unknown
BRIS-114 — Grant immunity for NHS staff reporting sentinel events within 48 hours
Recommendation: Members of staff in the NHS should receive immunity from disciplinary action by the employer or by a professional body if they report a sentinel event to the trust or to the national database within 48 hours, except where they …
Unknown
BRIS-113 — Make reporting of sentinel events easy using all communication means
Recommendation: The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Unknown
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
BRIS-25 — Extend consent process to all clinical procedures involving touching, focusing on communication
Recommendation: The process of consent should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication.
Unknown
BRIS-23 — Endorse and implement DoH consent guide across all NHS healthcare professional practice
Recommendation: We note and endorse the recent statement on consent produced by the DoH: ‘Reference guide to consent for examination or treatment’, 2001. It should inform the practice of all healthcare professionals in the NHS and be introduced into practice in …
Unknown
R69 — Explanation to relatives on CDI death
Recommendation: Health boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation.
Gov response: Section 4.2 of the Scottish Government's response emphasizes person-centred care, with a key aim to ensure people have sufficient knowledge and understanding of their health care. The "Must Do with Me" elements of person-centred care …
Accepted
CR17 — Protocol for duty to assist referrals
Recommendation: HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold for making a referral on a potential breach by a …
Response Pending
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Gov response: Trust disciplinary procedures updated to address professional code breaches independently.
Accepted
IHRD-72 — Candour in Trust Communications
Recommendation: All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.
Gov response: Non-executive Director oversight of Trust communications implemented.
Accepted
No update 2+ yrs
IHRD-69 — Executive Director Responsibilities
Recommendation: Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.
Gov response: Executive Director responsibilities assigned for candour, child healthcare and SAI learning.
Accepted
PFD Reports (39)
James Withers
Concerns: Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.
Overdue
Hilda Haughton
Concerns: Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of increased fire-door closing times in hospitals.
Response (Department of Health): The Department of Health issued an Estates and Facilities Safety Alert to the NHS in England regarding the speed of closing fire doors. The alert sets out necessary action to …
Response (Hilda Haughton): The trust states that the incident didn't invoke the Statutory Duty of Candour. The trust states they have been proactive in relation to ensuring Duty of Candour and gives information …
Responded
Frank Mellers
Concerns: The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led to resuscitation attempts despite the DNAR, and guidelines for DNAR communication may need examination.
Response (Frank Mellers): Following a Root Cause Analysis, the importance of ward rounds has been reiterated, a DNAR indicator has been developed on ward boards, the DNAR policy has been reviewed, and a …
Overdue
Jack Susianta
Concerns: Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Overdue
Sally Froggatt
Concerns: There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.
Overdue
Geraldine Butterfield
Concerns: Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.
Overdue
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR …
Response (CQC): The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend …
Response (NHS England): NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next …
Responded
David Lindsey
Concerns: The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust did not follow its own policies and guidelines.
Overdue
Francesca Whyatt
Concerns: Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.
Response (Priory Hospital): The Priory Hospital Roehampton details environmental and health and safety risk assessments undertaken and coordinated with Policy H43 Observation and Engagement throughout the ward. The Incident Management; Reporting and Investigation …
Overdue
Patricia Forshaw
Concerns: The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.
Response (Wrightington Wigan and Leigh NHS Trust): Wrightington, Wigan and Leigh NHS Trust has notified emergency care staff that calls should not be put through to minors or majors, that treatment advice should not be given, and …
Responded
Helen Cannon
Concerns: Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.
Response: Illegible response.
Overdue
Rose Ball
Concerns: A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the doctor's fitness to practice and highlighting wider public safety implications of such practices.
Overdue
Emmett Gillah
Concerns: Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. Staff were also unaware of KMPT's discharge policies.
Overdue
Elisa Fuller
Concerns: Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.
Response (Gloucestershire Hospitals NHS Trust): Gloucestershire Hospitals NHS Trust provided a mandatory update day for midwives, including a presentation on lessons learned from inquests. They have also developed a draft policy on placental retention and …
Responded
David Smith
Concerns: Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.
Response (Manchester University NHS Trust): Following acknowledgement that Mr. Smith's care fell below standard, the consent process for transplantation has been strengthened to specifically inform all recipients about CMV infection and its effects. A multidisciplinary …
Responded
Emma Langley
Concerns: The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.
Response (West Midlands Ambulance Service NHS Trust): West Midlands Ambulance Service is changing its electronic patient report software to include a clearer statement about refusing treatment/transport. They have also updated their policy on refusal of care and …
Responded
Andrew Wells
Concerns: The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.
Overdue
Ifeoma Onwuka
Concerns: An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.
Overdue
Agnes Sansom
Concerns: Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
Response (County Durham and Darlington NHS): Following review, physiotherapists now record changes in mobility or interventions in the Nervecentre system to ensure all staff are aware, in addition to maintaining detailed paper records. A buffer stock …
Responded
John Long
Concerns: Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.
Overdue
Peter Cole
Concerns: Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Response (NHS England): NHS England references the Long Term Plan as covering monitoring of repeat prescribing. It also highlights the Medicines Safety Improvement Programme and the Dementia Care Pathway guidance, both of which …
Responded
Susan Roberts
Concerns: There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.
Response (Bradford Teaching Hospitals NHS Foundation Trust): Bradford Teaching Hospitals issued a protocol for Necrotising Fasciitis cases specifying contact procedures and involved specialties. The Trust also revised its Serious Incident Reporting policy to ensure attendance of all …
Responded
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
Concerns: There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Response (City Hospital Campus): The hospital has taken or planned actions to improve ERCP patient pathways, vetting, consent, and accountability, including a specialist HPB endoscopy team and a meeting to design pathways for complex …
Responded
Robert Murray
Concerns: There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order should not be applied.
Response (NMC): The Nursing and Midwifery Council outlines existing standards and processes related to DNACPR understanding and fitness to practise, without describing new actions taken or planned.
Response (Adult Social Care): Avalon Nursing Home updated DNACPR and RESPECT forms in care plans, discussed clinical judgements with a local surgery and paramedics, provided refresher training in basic life support and first aid, …
Responded
Marnie Hill
Concerns: The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting of self-harm risks, poses a significant risk of future deaths.
Response (South Western Ambulance Service NHS Foundation Trust): SWASFT has reminded all Private Ambulance Providers (PAPs) of the Appropriate Care Pathway Policy regarding GP referrals and the Dorset Integrated Urgent Care Service (IUCS) GP Alert service. The ECS …
Response (NHS Dorset ICB): Dorset Integrated Care Board acknowledges the concerns but states Dorset has a well-established Access Mental Health service. They state SWASFT are in discussions with Dorset HealthCare and the police about …
Response (Department of Health and Social Care): The Department acknowledges the concerns raised and outlines the regulatory framework for health and care professionals. It details the SCoPEd framework being adopted by professional counselling bodies but notes these …
Responded
Samantha Shillito
Concerns: A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.
Response (Mid Yorkshire Teaching NHS Trust): The Trust will review patient safety leaflets in accordance with guidance from professional bodies such as the Royal College of Radiologists and British Society of Interventional Radiology to ensure they …
Response (The Royal College of Radiologists): The RCR acknowledges the concerns, noting points 1 and 4 are outside their remit. They endorse GMC guidance on consent and state they don't produce patient information leaflets.
Responded
Sarah Chappell
Concerns: Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Response (University College London Hospitals NHS Foundation Trust): UCLH has strengthened its governance structures, appointed a second learning disability nurse, instigated a process to review all deaths of patients with learning disabilities, convened a weekly incident review group, …
Responded
Benjamin Leonard
Concerns: The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.
Response (Charity Commission for England and Wales): The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA …
Response (Minister for Education Wales): The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to …
Response (Childrens Commissioner for Wales): The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work.
Response (Childrens Commissioner): The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role …
Response (Department for Education): The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions.
Response (Health and Safety Executive): HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout …
Response (Scout Association): The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They …
Response (Unity): Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding …
Responded
Olayemi Kehinde
Concerns: Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into the incident.
Response (NELFT): NELFT has implemented new guidance for leave from inpatient wards, including risk assessment and communication protocols, and has introduced weekly Patient Safety Incident Group forums to oversee incidents; they have …
Responded
Sophie Dean
Concerns: Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
Response (UCLH): UCLH will implement a standard ward round note with minimum information requirements, will audit notes within 12 months, has amended the consent policy to require a second consultant opinion for …
Responded
Janet Seddon
Concerns: A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.
Response (York Scarborough Teaching Hospitals NHS Foundation Trust): York & Scarborough Teaching Hospitals NHS Foundation Trust has implemented the Patient Safety Incident Response Framework (PSIRF), updated the Incident Management Policy and Duty of Candour Policy, and changed the …
Responded
Denise Johnson
Concerns: The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
Response (East Suffolk and North Essex Foundation Trust): The Trust is starting 3 monthly ERCP Multi-Disciplinary Team meetings to discuss all cases and complications. A cross-site SOP has been drafted and approved entitled “Patient Take Over During Sickness …
Responded
Cynthia Gilbert
Concerns: Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and the efficacy of post-death investigations.
Response (Somerset NHS Foundation Trust): Somerset NHS Foundation Trust commenced a QI project in September 2024 with an aim to improve the Intentional Rounding process, understanding, application and staff culture. The trust is also aiming …
Responded
Darren Turner
Concerns: Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.
Response (Essex Partnership University NHS Foundation Trust): The Trust is reinforcing the expectation of weekly care plan reviews, discussing care plans in weekly MDTs, auditing care plans via the Trust Tendable system, and implementing a new inpatient …
Responded
Mabel Williams
Concerns: The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow and reactive.
Response (Great Western Hospitals NHS Foundation Trust): The Trust has revised the "Birth After Previous Caesarean" patient information leaflet with a clear explanation of uterine rupture and its potential consequences. They have also implemented a mandatory training …
Responded
William King
Concerns: Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a risk of recurrence.
Response (Royal College of Surgeons of England): The Royal College of Surgeons is updating its guidance on consent, developing practical tools and checklists for implementation, and creating an e-learning module on consent for hospitals to use for …
Response (Association of Anaesthetists and Royal College of Anaesthetists): The Association of Anaesthetists and Royal College of Anaesthetists are publishing a Good Practice guide on rapid sequence induction (RSI), emphasizing the need for patients to understand the risks associated …
Response (Milton Keynes University Hospitals NHS Foundation Trust): The Trust is developing an electronic form to assist staff in navigating and documenting discussions with patients who choose 'care outside of guidance,' planned for implementation in the New Year …
Responded
Amber Walker
Concerns: Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Response (Department of Health and Social Care): The Department of Health and Social Care references NICE guidance on epilepsy, the Epilepsy Self-Management Programme, and the Clive Treacey Checklist regarding SUDEP risk assessment. They note that medical schools …
Responded
Lee Eustace
Concerns: An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information to the Coroner.
Response (University Hospitals Plymouth NHS Trust): University Hospitals Plymouth NHS Trust has completed a full investigation, made improvements to learning from deaths and mortality review processes including reviews by Divisional Quality Teams, Stage 1 mortality screening …
Responded
Graham Oxley
Concerns: Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated fast-track pathway for specialist care.
Responded
Committee Recommendations (9)
#10 —
Recommendation: The failure of health and social care bodies to fulfil their duty of candour to bereaved people during coroners’ investigations and inquests is disappointing. The Ministry of Justice should amend the Coroners’ rules to make it patently clear that the …
Gov response: The Charter for Families Bereaved through Public Tragedy proposed by Bishop James Jones contains a commitment by public bodies to approach inquests with candour and honesty, making full disclosure of relevant documents, material and facts …
Under Consideration
#17 —
Recommendation: It is clear to us that in its current form the clinical negligence process is failing to meet its objectives for both families and the healthcare system. Too often families are not provided with the appropriate, timely and compassionate support …
Gov response: 81. We reject this recommendation. The Government does not intend to put in place a Rapid Redress and Resolution Scheme, as explained in the Department’s evidence to the Committee in February 2021. 82. The Department …
Not Addressed
#37 — Formally consider introducing a professional duty of candour to increase police transparency.
Recommendation: We recommend that the NPCC, College of Policing, Home Office and Association of Police and Crime Commissioners formally consider whether a professional “duty of candour” might drive greater transparency in policing. We consider that, while this would not be enough …
Gov response: 95. PCCs have existing statutory responsibilities for setting the policing and crime objectives for their area, and for holding the Chief Constable to account for running the force.
Accepted
#22 —
Recommendation: Finally, given their recognition of the role the professional regulators have in ending the blame culture, we recommend that the General Medical Council and the Nursing and Midwifery Council review what changes are required to their remits or working practices …
Gov response: 87. We welcome the Committee’s recommendation that the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) have a role to play in helping to end the blame culture that currently exists in …
Not Addressed
#11 —
Recommendation: We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, …
Gov response: 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions …
Not Addressed
#10 —
Recommendation: Involving families in a compassionate manner is a crucial part of the investigation process. Too often, maternity investigations have failed to do this in a meaningful way. Families must be confident that their voices are heard and that lessons have …
Gov response: 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions …
Not Addressed
#12 —
Recommendation: Clinicians of all disciplines should also receive training before they are qualified in how they should respond to the sorts of error that these investigations may uncover. This would include help for clinicians on accepting a degree of fallibility. Being …
Gov response: 102. We accept this recommendation. 103. NHSEI agrees that all professionals involved in maternity care should be competent and confident in all areas of their work, including when working in Continuity of Carer teams or …
Not Addressed
#11 — Mandate Ofgem and energy companies to adopt a proactive culture improving consumer standards.
Recommendation: Ofgem and energy companies need to adopt a more proactive culture in improving industry consumer standards. Energy companies should not wait to be enforced to certain standards by Ofgem but should be innovating to improve customer satisfaction and attract more …
Gov response: As the independent regulator, Ofgem is responsible for setting and enforcing the rules on supplier requirements and customer standards. However, this is also a topic that the Government is focused on. At a time when …
Not Addressed
#10 — Ofgem and energy companies failed to proactively improve consumer standards for winter.
Recommendation: While we welcome the forthcoming set of consumer standards, we are disappointed that Ofgem did not anticipate the need for significant improvements ahead of this winter. Introducing them from December 2023 will likely be too late to see significant 12 …
Gov response: As the independent regulator, Ofgem is responsible for setting and enforcing the rules on supplier requirements and customer standards. However, this is also a topic that the Government is focused on. At a time when …
Not Addressed
CQC Inspection Actions (16)
Verve Health
The service must ensure staff are applying the duty of candour when things go wrong.
Must Do
Edwina Place
The provider should seek advice and guidance from a reputable source about Regulation 20: Duty of Candour to ensure requirements are met at all times, including clear record keeping.
Should Do
Universal Care - Beaconsfield
We recommend the provider seek guidance from a reputable source to ensure the duty of candour requirements are fully understood by all staff.
Should Do
My Homecare Peterborough
The provider had failed to notify the Care Quality Commission about incidents they are required to.
Must Do
Kingfishers Nursing Home
The service implements a system to meet the requirements of the duty of candour process.
Should Do
Gallaudet Home
We recommend that the manager ensures they update their knowledge on the duty of candour from a reliable source and take action to update their practice accordingly
Should Do
Universal Care - Beaconsfield
the provider sought guidance from a reputable source to ensure the duty of candour requirements were fully understood by all staff.
Should Do
Nicholas House
The provider must ensure that the registered provider acts in an open and transparent way with relevant persons when notifiable events occur.
Must Do
Kingsleigh Residential
The provider had failed to ensure correct information was given to people when something had gone wrong.
Must Do
Shining Star Home Care Limited
There were gaps in the providers knowledge of when notifications were required to be submitted. We found that allegations of abuse notifications had not been submitted, as the provider's knowledge of when these types of notification should be sent was …
Should Do
Shining Star Home Care Limited
Improvements were needed in the providers systems to ensure the CQC were notified of events around allegations of abuse.
Should Do
Church Road
The provider ensures all staff and managers are familiar with the requirements of the regulations regarding duty of candour so they act in accordance with these.
Should Do
Cygnet Bury Hudson
The provider should ensure that all staff know what the specific roles are in relation to independent mental health advocates and independent mental capacity advocates and have a good understanding of the duty of candour.
Should Do
Medrescue Headquarters
TheservicemustensurethatitfollowscorrectprocesswhensubmittingstatutorynotificationstotheCQCunder theirresponsibilityasaregisteredprovider.
Must Do
The Elms
The registered manager must notify CQC of all reportable incidents.
Must Do
The Olde Coach House
The provider seeks advice and reviews their policy and practice relating to notifiable events to the CQC.
Should Do
ICIBI Immigration Recommendations (3)
An inspection of asylum casework (June - October 2023)
Introduce, as a matter of urgency, a published service standard
An inspection of the immigration system as it relates to the social …
Work in partnership with the responsible government departments and agencies to agree a concise ‘migrant’s guide to UK employment rights’, which can be proactively shared with migrants at the earliest …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to initial age assessments and decisions: Publish guidance on the ‘age admit’ process, setting out the steps required to ensure that anyone asked to sign a ‘Statement of …
PPO Death in Custody Recommendations (1)
PHSO Ombudsman Recommendations (1)
IMB Recommendations (4)
Lowdham Grange (2024)
What action is being taken to address HM Coroner’s stated concerns, including: a failure to investigate whether anything could have been done to prevent the deaths; failure to seek any lessons from the deaths; failure to implement any findings of the Prisons and Probation Ombudsman (PPO); and the failure to inform staff of policies and procedures relating to the deaths, …
Governor / Director
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Governor / Director
Tinsley House IRC (2020)
to ensure that HOIE Rule 35 notification responses are tailored to the individuals to whom they relate, and that those responses are genuinely meaningful.
Home Office
Derwentside IRC (2023)
To ensure that all residents are made aware of rule 35 on arrival to enable access to a medical practitioner and provision of reports to case-owners as soon as possible after arrival in detention.
NHS / Healthcare Provider
Health Investigations (3)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 7b
A specialist sub-committee of the National Strategic Oversight Board should oversee Health Boards' delivery of the perinatal National Reportable Incident process, ensure timely, multidisciplinary and family-centred responses, and produce national thematic learning.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 7a
A clear, accessible and publicly available Standard Operating Procedure for maternity and neonatal incident response should be published for Wales underpinned by family-centred, trauma-informed and restorative approaches.
wales
Accepted
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must assure itself that all practices of seclusion and ‘de facto’ seclusion on the PICU, including where patients have been segregated from others after rapid tranquilisation, are fully compliant with the requirements of the Mental Health 1983 (amended 2007), the MHA Code of Practice and the MHA Reference …
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
Accepted
Detention Investigations (3)
Assessment of government progress in implementing the report on the … — Rec 18
NHS England should continue to roll out staff training on SystmOne/HJIS, and should make sure that patient consent is consistently recorded by conducting a national case fle audit and ensuring that this is a mandatory feld in HJIS.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 50
I recommend that the Home Office, in consultation with NHS England, draw up explicit guidelines as to: • What informed consent looks like • What information can be shared between all parties in the event that informed consent to the release of clinical information is granted by the detainee.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 6
Given my observations at each of the Heathrow terminals and at Cayley House, Tascor should arrange for refresher training for its staff on their duty of care, and the need for proper and meaningful engagement with detainees.
Immigration Detention
PHSO Casework Decisions (134)
P-001575 — Mid and South Essex NHS Foundation Trust
Mrs O complains about the care and treatment her father, Mr M, received from the Trust between 7 and 23 April 2020. She complains on 7 April the Trust put a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) in place without telling her. She also says the Trust should not have …
NHS in England
Oct 2022
P-001956 — Homerton Healthcare NHS Foundation Trust
Mrs Y complains the Trust did not tell her or her husband about his cancer diagnosis after a CT scan. She also complains it discharged him despite saying he needed to stay to have strong antibiotics and about how it communicated the seriousness of his condition.
NHS in England
Apr 2023
P-002480 — Manchester University NHS Foundation Trust
Mr C complains that in January 2022 the Trust prescribed steroids for an eye condition but did not tell him about all the possible side effects. He says this meant he was not able to make an informed decision about whether to take the steroids.
NHS in England
Upheld
Nov 2023
P-001147 — Portsmouth Hospitals NHS Trust
Mr H complains that the Trust did not seek consent or advise him of the risks, including its permanent nature, before it performed a dorsal slit procedure on him.
NHS in England
Upheld
Oct 2021
P-001680 — Gateshead Health NHS Foundation Trust
Mrs T complains about her mother's inpatient stay at the Trust from 21 January to her discharge on 29 January 2021. She complains about poor communication, errors during discharge and errors in the do not attempt cardiopulmonary resuscitation (DNACPR) in place. She also complains the Trust has not learned from …
NHS in England
Dec 2022
P-001751 — Royal United Hospitals Bath NHS Foundation Trust
Mr D complains the Trust did not give him appropriate information about the risks of a colonoscopy and a polypectomy before he had the procedures in April 2019.
NHS in England
Partly Upheld
Jan 2023
P-001874 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs B complains she did not consent to a junior doctor administering spinal anaesthesia. She says the junior doctor had not done this procedure before and she thinks something went wrong causing her to experience ongoing non-epileptic seizures. Mrs B also says a ward nurse tried to bring her out …
NHS in England
Mar 2023
P-001882 — South Warwickshire NHS Foundation Trust
Mrs U complains the Trust added a 'Do Not Attempt to Resuscitate' (DNAR) notice to her husband's records without telling her. She also complains it failed to do blood tests and to give the correct medication when needed, and it did not tell her when her husband died.
NHS in England
Mar 2023
P-001906 — Moorfields Eye Hospital NHS Foundation Trust
Miss W complains the Trust did not tell her about the risks of her cataract operation, it made a mistake during the procedure, and it did not report this after the procedure.
NHS in England
Mar 2023
P-003282 — Somerset NHS Foundation Trust
Mrs L complained the Trust did not use a consent procedure before her breast biopsy. She complained something went wrong with the procedure and the Trust did not tell her there had been a complication. She also complains the Trust did not give her enough aftercare and she still has …
NHS in England
Partly Upheld
Apr 2023
P-002354 — Liverpool University Hospitals NHS Foundation Trust
Ms A complains the Trust failed to uphold its duty of candour and lied about events that led to her having a cardiac arrest and being placed in a coma. She also says it gave misleading information about the cause for her condition, gave her an overdose of adrenaline and …
NHS in England
Dec 2023
P-003286 — East Sussex Healthcare NHS Trust
Miss H complains about the Trust’s care and treatment between 2012 and 2021. She complains the Trust failed to tell her about the long-term complications of the endometrial ablation procedure (treatment for heavy periods).
NHS in England
Partly Upheld
Mar 2024
P-003122 — London North West University Healthcare NHS Trust
Mr A complains the Trust administered lifesaving treatment without his informed consent.
NHS in England
Nov 2024
P-003437 — University Hospitals of Derby and Burton NHS Foundation …
Mr Z complains the Trust did not inform his wife about the development and prognosis of her cancer meaning there was a lost opportunity for her to change treatment.
NHS in England
Upheld
Mar 2025
P-003448 — East Sussex Healthcare NHS Trust
Miss B and her mother complain East Sussex Healthcare NHS Trust administered the wrong medication to Mr B just before he died, denied it gave him it and did not record this properly in the medication chart. They also complain it did not contact them soon enough when Mr B …
NHS in England
Partly Upheld
Mar 2025
P-004205 — A practice in the Darlington area
Ms O complains about the care her father received from a GP practice in North-East England between May and October 2022. She complains the Practice failed to diagnose a serious ear infection promptly, breached its Duty of Candour, and handled her complaint poorly.
NHS in England
Partly Upheld
Sep 2025
P-004593 — University College London Hospitals NHS Foundation Trust
Mrs R complains about aspects of the medical treatment clinicians gave to her father in hospital during the last few days of his life. She is also unhappy about how they communicated with her and has concerns relating to consent and resuscitation decisions.
NHS in England
Not Upheld
Jan 2026
P-001782 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mr A complains Trust staff did not provide appropriate treatment to his mother. He also complains the Trust made treatment decisions without her consent, it did not update him on her care until he called and it did not not handle his complaint properly.
NHS in England
Feb 2023
P-001791 — Barts Health NHS Trust
Ms R complains the Trust's communication about her father's treatment was poor and there were long delays in her father being given his morphine injections.
NHS in England
Upheld
Feb 2023
P-001876 — A dental practice in the Kingston upon Thames …
Mr R complains the Practice cemented a crown in place without letting him check it first. He also complains that after fitting the crown, the Practice told him it cannot be removed.
NHS in England
Upheld
Mar 2023
P-003284 — University Hospitals Birmingham NHS Foundation Trust
Miss O complains about the treatment her sister received in June 2021. Miss O complains the Trust failed to get consent and instead forced her sister to be catheterised. She also complains about delays in the Trust’s complaint handling.
NHS in England
Upheld
Sep 2023
P-002365 — King's College Hospital NHS Foundation Trust
Mrs D complains on behalf of her father about how the Trust used do not attempt cardiopulmonary resuscitation (DNACPR) notices. She says a DNACPR form was completed without her father’s or his family’s consent, his records incorrectly say he consented to the DNACPR, his wishes to be resuscitated were ignored …
NHS in England
Dec 2023
P-002650 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr and Miss U complain about the care and treatment the Trust gave to their father. They say doctors made a DNACPR decision against the family’s wishes and his religious beliefs, staff did not provide enough information and updates and staff were rude, obstructive and unprofessional.
NHS in England
May 2024
P-002752 — A practice in the City of Derby area
Mr and Mrs R complain about the care and treatment the Trust provided during Mrs R's pregnancy and the birth. They complain the staff did not direct Mrs R to services, it did not support her to write a birth plan and staff did not tell her what was happening, …
NHS in England
Partly Upheld
Jul 2024
P-003285 — Warrington and Halton Hospitals NHS Foundation Trust
Miss E complains about the Trust’s treatment during her labour in October 2021. She complains staff ignored her wishes and gave her medical procedures without her consent.
NHS in England
Upheld
Jul 2024
P-002892 — Guy's and St Thomas' NHS Foundation Trust
Mr R complains about how the Trust cared for his wife. He says doctors did not tell him how serious her condition was, they wrongly gave her chemotherapy, there was no continuity of care and the Trust would not let him take his wife abroad for treatment.
NHS in England
Aug 2024
P-002990 — University Hospitals Dorset NHS Foundation Trust
Mr D complains about the care and treatment given to his wife. He complains about delays, failure to recognise symptoms, treatment decisions and communication.
NHS in England
Partly Upheld
Aug 2024
P-002839 — Barts Health NHS Trust
Mrs R complained about the care and treatment the Trust gave her husband in January 2021. She said the Trust put a DNACPR order in place when it should not have and failed to consult the family before making this decision. She also said it did not provide adequate nursing …
NHS in England
Upheld
Aug 2024
P-002916 — Barts Health NHS Trust
Ms P complains the Trust did not communicate appropriately about her father’s condition and prognosis. She also complains the Trust delayed prescribing and later withdrew medication without consent, and it did not meet her father’s nutritional needs.
NHS in England
Sep 2024
P-002950 — County Durham and Darlington NHS Foundation Trust
Mrs U complains about the Trust’s care and treatment of her father. She says the communication was poor, there was no overall treatment plan or care planning, the Trust did not meet or assess his nutrition or hydration needs and it did not recognise when he was at the end …
NHS in England
Partly Upheld
Sep 2024
P-002952 — Mid Yorkshire Teaching NHS Trust
Mrs A complains Mid Yorkshire Teaching NHS Trust sent Mr A home when his diabetes was not stable. Mrs A also says it incorrectly informed her about his pneumonia diagnosis and did not tell her how unwell Mr A was when it put a DNACPR in place.
NHS in England
Sep 2024
P-002945 — Manchester University NHS Foundation Trust
Miss U complains about the care and treatment when she was sectioned under the Mental Health Act. She said staff used inappropriate physical force and did not tell her about several aspects of her treatment.
NHS in England
Sep 2024
P-002938 — University Hospitals of Derby and Burton NHS Foundation …
Mrs A complains about the care and treatment the Trust gave to her husband. She says it put a Do Not Attempt Resuscitation (DNAR) Order in place without the family’s input or knowledge. She also complains it wrongly gave him opioid pain relief and did not monitor him for side …
NHS in England
Sep 2024
P-003093 — East Suffolk and North Essex NHS Foundation Trust
Miss O complains about the Trust’s care and treatment of her sister between February and March 2023. She says the Trust failed to give her sister the right treatment and did not communicate with the family when her condition deteriorated.
NHS in England
Partly Upheld
Oct 2024
P-003027 — Walsall Healthcare NHS Trust
Mr L complains about the care and treatment provided to his partner in January 2022. He also complains about a lack of communication between the clinical teams and the family.
NHS in England
Oct 2024
P-003136 — The Royal Wolverhampton NHS Trust
Mr F complains the Trust wrongly told him he had cancer which required surgery. He also complains the Trust did not offer him appropriate post-surgical care and support.
NHS in England
Nov 2024
P-003270 — North Bristol NHS Trust
Mrs L complains that after she contacted the Trust, before her breast screening appointment in March 2020, it incorrectly recorded that she declined to attend and did not send her a further invitation. She is also concerned it has not acknowledged it made an error and has not apologised or …
NHS in England
Partly Upheld
Jan 2025
P-003295 — South Tyneside and Sunderland NHS Foundation Trust
Miss U complains the Trust did not provide her mother with adequate hydration in October 2021. Miss U also complains the Trust did not communicate with her regarding its Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision.
NHS in England
Upheld
Jan 2025
P-003274 — United Lincolnshire Teaching Hospitals NHS Trust
Ms N complains the Trust delayed her brother’s treatment for oesophagus cancer, did not tell him his prognosis was less than one year and did not show any compassion. She also complains about the compassion and palliative care.
NHS in England
Jan 2025
P-003335 — East Suffolk and North Essex NHS Foundation Trust
Mrs B complains about the Trust’s fertility treatment. She also complains about how it handled her complaint.
NHS in England
Feb 2025
P-003329 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs T complains about the care provided to her late father by the Trust between March 2020 and June 2021. She complains about the communication, consent, and capacity processes followed by the Trust in the lead up to surgery, as well as the way the Trust handled the reporting and …
NHS in England
Partly Upheld
Feb 2025
P-003394 — London North West University Healthcare NHS Trust
Ms E complains the Trust did not contact her when her father died and she arrived to visit him not knowing he had died. She also complains about aspects of her father’s care in his final days.
NHS in England
Mar 2025
P-003397 — Buckinghamshire Healthcare NHS Trust
Mr E complains about aspects of care his wife received in hospital in the last few days of her life. He also believes there was poor communication and complaint handling. He questions whether his wife’s death was avoidable.
NHS in England
Mar 2025
P-003499 — Barts Health NHS Trust
Miss H complains following her mother’s admission to the Trust in September 2023. She complains it did not get the family’s consent for procedures and its communication was not good.
NHS in England
Apr 2025
P-003517 — University College London Hospitals NHS Foundation Trust
Mrs C complains about Mr C’s experience with the Trust in March 2024. She says the Trust changed the location of Mr C’s appointment at short notice, the doctor Mr C saw was rude, dismissive and lacked compassion and the letter the Trust sent after the appointment was inaccurate.
NHS in England
Apr 2025
P-003513 — Somerset NHS Foundation Trust
Mrs U complains the Trust told her about the outcome of her surgery in an insensitive way and that it changed its diagnosis when she queried it. She also says it refused to do regular MRI scans, put her on the wrong treatment plan and was not helpful when handling …
NHS in England
Apr 2025
P-003522 — Medway NHS Foundation Trust
Miss A complains about the care and treatment her father received from May to June 2022. Miss A also complains about the Trust’s communication.
NHS in England
Apr 2025
P-003550 — University Hospitals of Derby and Burton NHS Foundation …
Mrs R complains about the care and treatment the Trust gave to her husband in June 2022. She complains about delays in treatment, conduct of staff, communication and complaint handling.
NHS in England
May 2025
P-003586 — Lewisham and Greenwich NHS Trust
Miss Q complains staff did not respond to her father’s deterioration, they did not discuss resuscitating him, and they failed to inform her about her father’s death.
NHS in England
Jun 2025
P-003699 — Sherwood Forest Hospitals NHS Foundation Trust
Mrs A complained the Trust's care of her husband in May and June 2022 fell below an acceptable standard and that the Trust failed to communicate effectively with her family. She also complained about the Trust's complaint handling.
NHS in England
Upheld
Jul 2025
LGO / SPSO Decisions (213)
201507796 — A Pharmacy in the Lanarkshire NHS Board area
Mrs C contacted a pharmacy by phone for an emergency supply of her prescribed medication. She told us the pharmacist refused her request a number of times and that she was treated rudely and asked unreasonable and irrelevant questions. Mrs C complained to us that the pharmacy had not responded …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jan 2017
NIPSO-202003197 — Western Health and Social Care Trust
A woman complained about the treatment her father received in Altnagelvin Hospital, including that he should not have had a catheter inserted while he was dying. We upheld parts of the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2024
NIPSO-202002149 — Northern Health and Social Care Trust
The Northern Trust failed to keep proper records of a patient's food intake, and didn't provide him with insulin after he experienced an episode of hypoglycaemia.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
NIPSO-202003606 — Western Health and Social Care Trust
The Northern Trust should have told a patient and his family that he would not be resuscitated if his heart or breathing stopped.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2025
NIPSO-202005907 — Northern Health and Social Care Trust
The Northern Trust also failed to carry out a proper investigation when the patient complained.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jan 2026
PSOW-202507139 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in April 2025. The Ombudsman found that the Health Board failed to provide Mrs X with a complaint response which the Ombudsman said caused uncertainty and frustration for Mrs X. The Ombudsman decided …
PSOW (Public Services Om…
Health
Jan 2026
PSOW-202507953 — Hywel Dda University Health Board
Ms G complained that Hywel Dda University Health Board failed to issue a response to her complaint, which she made to it in April 2025, regarding the care and treatment provided to her late partner. The Ombudsman found that the Health Board had failed to issue a complaint response. She …
PSOW (Public Services Om…
Health
Jan 2026
20-010-932-report — Hamilton Care Ltd
Summary: Adverse Findings Notice issued because Hamilton Care Ltd failed to provide part of the recommendation to remedy a complaint by the Ombusman.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
20-012-369 — London Borough of Newham
Summary: Ms Z, on behalf of her mother Ms X, complained about the Council’s action in respect of her finances. There is fault by the Council in failing to start a safeguarding investigation at the appropriate time; delay in progressing a safeguarding investigation and failure to ensure Ms X's needs …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-009-828 — Devon County Council
Summary: Mr X complained about how the Council communicated with him about the costs of care for his late wife Mrs X. Mr X said he received a large, unexpected bill which caused him a great deal of stress and the Council did not answer his questions about this. We …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-016-410 — The North Northumberland Hospice
We upheld a complaint about end-of-life care. The Care Provider will apologise and review its procedures for record-keeping.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-003-612a — Livewell Southwest (21 003 612a)
Summary: Ms X complains about a lack of care and support provided to her late sister, Ms Y. Ms X says this enabled Ms Y to ingest items she should not have had access to, and that a serious incident report did not answer some of her questions about what …
LGO (Local Government & …
Health
Upheld
Jun 2022
21-016-787 — Kent County Council
Summary: Mr X complains the Council’s care provider, Expertise Homecare (Ashford), failed to meet his late mother’s needs, putting her at risk of harm. His mother did not always receive person centred care and was put at risk of harm by some of her care workers. This caused avoidable distress …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-003-599 — By Your Side Ltd
Summary: Mr X complained on behalf of him and his late mother about how the Care Provider charged them for home care. The Care Provider was at fault for not clearly explaining the care charges, for sending insufficiently detailed invoices and for failing to readvertise for live-in care. It should …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-003-308 — North Yorkshire County Council
Summary: The complainant (Mrs X) said the Council failed to follow the right process when charging her for care services. The Council accepted its fault and offered to waive Mrs X’s outstanding care charges and remind its staff of the need to provide advance information on charging. There is nothing …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
22-004-838 — London Borough of Richmond upon Thames
Summary: Mr Y, complained on behalf of his father Mr X, about the Council’s failure to provide information that long term care would be chargeable. We have not found fault with the Council in how it informed Mr X and his family about care charges. There was fault for sending …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-010-329 — London Borough of Hillingdon
Summary: Miss Y complains about the Council’s actions in relation to a package of home care it commissioned in 2022. The Council upheld some parts of the complaint and Miss Y has received a remedy which we consider to be appropriate. We do not find fault in the other parts …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
23-007-717 — Regent Home Care (West Herts) Limited
Summary: Miss Y complains about the home care provided to her mother, Ms W. The care provider upheld some parts of her complaint, apologised and made service improvements. We have identified some fault in one of the complaints which the care provider has agreed to apologise for and provide a …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
24-007-464 — Bristol City Council
Summary: We will not investigate this complaint about quality of service provided to Mr X by two care providers. The Council has already taken suitable action to remedy injustice caused to Mr X.
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
24-011-103 — Slough Borough Council
Summary: Mr X complained about the Council’s actions linked to reports of a vehicle which belonged to him being abandoned. We found fault as the Council gave out an incorrect telephone number and did not respond to an email from Mr X in a timely manner. This caused Mr X …
LGO (Local Government & …
Environment And Regulation
Upheld
Jun 2025
24-011-650 — Cambridgeshire County Council
Summary: Ms Y complained about how the Council charged her son, Mr X, for a contribution to his care and support and tried to collect a debt from him. There was fault in how the Council communicated with Mr X and Ms Y, with some of the action it took …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-020-292 — Norfolk County Council
Summary: Mr X complained the Council provided incorrect and misleading information about funding his mother’s residential care. We found the Council at fault because of poor communication and delay which caused avoidable distress, frustration and uncertainty. The Council has agreed to apologise and make a symbolic payment to Mr X …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
201204572 — Lothian NHS Board
Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2014
201400370 — Dumfries and Galloway NHS Board
Mr and Mrs C complained to the board about how a bone marrow sampling procedure was carried out on Mrs C. Some weeks after making the complaint Mrs C died. Mr C felt the board's response to their complaint was inadequate, and so he complained to us. We looked at …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2014
201401305 — A Dentist in the Lothian NHS Board area
Mrs C complained that part of her dental work was provided on a private basis without her prior knowledge or consent. She said that she was not given a written treatment plan or cost comparison before the treatment was carried out. The dentist said that Mrs C was given a …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2015
201401586 — Lanarkshire NHS Board
Mrs C was unhappy with a phone consultation she had with an out-of-hours GP. Specifically, Mrs C complained that the GP failed to visit her at home or arrange a visit by another GP, and that the GP terminated the phone consultation and gave an inaccurate account of the phone …
SPSO (Scottish Public Se…
Health
Partly Upheld
Feb 2015
201400888 — Lanarkshire NHS Board
Ms C, who is an advice worker, complained on behalf of her client (Ms A) about the actions of a health visitor in relation to a burn to Ms A's child's arm. The burn was treated at the time by the child's grandmother, who is a healthcare professional. Some weeks …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2015
201404362 — Grampian NHS Board
Mr C complained about the board's handling of his complaint. He had tried to speak to staff about a friend in hospital, and complained that the staff gave him inaccurate information about the board's policy on restrictions on providing information about patients. When the board investigated the complaint they also …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2015
201302557 — Grampian NHS Board
Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer in 2011 and had chemotherapy (a treatment where medicine is used to kill cancerous cells). In 2012, he was admitted to Aberdeen Royal Infirmary twice. Mrs C said that during the second admission a doctor told Mr A his …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2015
201404795 — Greater Glasgow and Clyde NHS Board
Mr C complained that a nurse in a prison health centre did not deal with his referral form appropriately. Mr C asked to see the mental health team and he outlined his reasons for his request. A nurse discussed his referral with him and asked questions that Mr C felt …
SPSO (Scottish Public Se…
Health
Not Upheld
Apr 2015
201403639 — A Medical Practice in the Grampian NHS Board …
Miss A was unhappy with the advice she had received on the management of her hypothyroidism (where the thyroid gland produces too little thyroid hormone) with regards to conception and pregnancy. Mrs C, who complained on behalf of Miss A, added that Miss A had complained that she was never …
SPSO (Scottish Public Se…
Health
Not Upheld
Apr 2015
201501220 — A Medical Practice in the Greater Glasgow and …
Ms C attended an appointment at her GP practice with a three-week history of constipation, vaginal bleeding and abdominal pain. Ms C was asked by her GP if she could be pregnant and Ms C said she was not. Ms C carried out a pregnancy test that same evening, and …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201501178 — Tayside NHS Board
Mr C saw a podiatrist because of the deteriorating condition of his foot due to an ulcer. He then had several admissions to Ninewells Hospital as well as being seen as an out-patient. He underwent an artery bypass (a procedure to improve blood flow) from just below the knee to …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500956 — Highland NHS Board
Mr and Mrs C complained to us that the board had failed to inform Mrs C of a diagnosis of diverticulitis (a common disease of the digestive system) that was reached when she had a colonoscopy (examination of the bowel with a camera on a flexible tube) under the Scottish …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500935 — Forth Valley NHS Board
Mr C complained that a prison health centre failed to refer him to a plastic surgery clinic for scar revision. This was in relation to scars on his abdomen which were causing him pain and discomfort. We took independent advice on the complaint from a GP. We were informed that …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500884 — A Dentist in the Lothian NHS Board area
Mrs C sustained nerve damage following dental treatment she received in 2014. She also complained that the dentist failed to respond to the Edinburgh Dental Institute (EDI)'s request for further information after she was referred there for further review. We sought independent advice from a general dental practitioner. We considered …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500696 — Ayrshire and Arran NHS Board
Ms C complained about the care and treatment she received from University Hospital Crosshouse for what she believed was suspected appendicitis. She said she made frequent visits to the A&E department at the hospital and was also admitted to the hospital, but her condition was not reasonably assessed and treated. …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500693 — Ayrshire and Arran NHS Board
Mr C complained about the care and treatment that his late wife (Mrs A) had received at University Hospital Crosshouse across a number of admissions. Mr C was concerned that staff were overly focussed on Mrs A's existing conditions and did not pay enough attention to new symptoms that were …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201500442 — Lanarkshire NHS Board
Mr C complained to us that staff at Monklands Hospital had failed to provide his mother (Mrs A) with appropriate clinical treatment in relation to her nasojejunal (NJ) feeding tube (a tube placed through the nose and into the small bowel to maintain nutrition when patients are unable to take …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201500354 — Fife NHS Board
Mrs C complained to us about the care and treatment provided to her late mother (Mrs A) in the Victoria Hospital. We took independent advice on Mrs C's complaints from a consultant geriatrician and a nursing adviser. Mrs C complained that the action taken in relation to the management of …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500246 — Lothian NHS Board
Mr C complained to us about the care and treatment his son (Mr A) received when he was admitted to the Royal Edinburgh Hospital under a short-term detention certificate under the Mental Health Act. Mr A has severe autism, learning disabilities and epilepsy. We took independent advice on Mr C's …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201500190 — Tayside NHS Board
Mrs C was referred to Perth Royal Infirmary due to a missing intrauterine system (IUS - a contraceptive device). A scan showed the IUS could be in her abdomen, but she was then found to be pregnant, so no x-ray could be done to confirm the exact location. The pregnancy …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201407891 — Golden Jubilee National Hospital
Mr C complained that the Golden Jubilee National Hospital did not carry out his knee surgery properly and that his aftercare was of a poor standard. He also had concerns about the consent he gave for the procedure as he was under the impression that his named consultant would mainly …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201407889 — A Medical Practice in the Ayrshire and Arran …
Ms C complained about the treatment her father (Mr A) received from the practice over a five month period in 2013. Mr A had been diagnosed with bladder cancer in 2012 and attended the practice on a number of occasions complaining of back pain. Ms C did not feel that …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201407064 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C, who works for a voluntary agency, complained about the care and treatment that her client (Mrs A) had received during admissions to the Southern General Hospital, the Victoria Infirmary and the New Victoria Infirmary. Mrs A was initially admitted after a fall where she broke her arm and …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201406424 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C complained to us about the medical and nursing care her mother (Mrs A) received at the Royal Alexandra Hospital before her death from heart failure. We took independent advice on Ms C's complaints from a nursing adviser and from a medical adviser who is a consultant physician and …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201406354 — A Medical Practice in the Greater Glasgow and …
Mr C was suffering from hoarseness and was referred to hospital by the medical practice for an out-patient appointment at the ear, nose and throat (ENT) department. He was seen by a consultant who identified no suspicious findings and he was discharged back into the care of the practice. Mr …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201802018 — Golden Jubilee National Hospital
Mrs C complained on behalf of her husband (Mr A). Mrs C said Mr A had undergone an operation on his heart, which they had believed would be routine and uncomplicated. Mr A suffered serious complications during the surgery, resulting in a long period of recuperation and life altering consequences. …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2019
201800796 — Fife NHS Board
Mrs C complained to us that nursing staff failed to document her concerns appropriately at a pre-operative assessment before she had a wisdom tooth surgically removed. She said that she told them that she was extremely anxious and that it was agreed that she would be taken first on the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2019
25-002-971 — Telford & Wrekin Council
Summary: We will not investigate Mrs X’s complaint that a carer shouted at her during a telephone call and falsely accused Mrs X of leaving many voicemails. This is because any injustice arising is not significant enough to warrant an investigation.
LGO (Local Government & …
Adult Care Services
Dec 2025