Feedback not integrated
60 items
2 sources
Failure of service providers to systematically collect and integrate feedback from staff, service users, and relatives to inform improvements.
Cross-Source Insight
Feedback not integrated has been flagged across 2 independent accountability sources:
31 inquiry recs
29 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (31)
BAHA-46 — Lessons Learned Process
Recommendation: The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and …
Gov response: Accepted. Lessons learned processes have been improved for faster dissemination.
Accepted
Delivered
BRIS-163 — Provide training and guidance to properly support public involvement processes
Recommendation: The process of public involvement must be properly supported, through for example, the provision of training and guidance.
Unknown
BRIS-164 — Provide financial resources to support public involvement, covering costs like childcare
Recommendation: Financial resources must be made available to enable members of the public to become involved in NHS organisations: this should include provision for payments to cover, for example, the costs of childcare, or loss of earnings.
Unknown
BRIS-165 — NHS Modernisation Agency to advise on achieving widest public and patient involvement
Recommendation: The involvement of the public, particularly of patients, should not be limited to the representatives of patients’ groups, or to those representing the interests of patients with a particular illness or condition: the NHS Modernisation Agency should advise the NHS …
Unknown
BRIS-166 — PCTs must involve public in commissioning hospital services and gather feedback
Recommendation: Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views …
Unknown
BRIS-28 — Routinely seek, act on, and publish patient feedback and experience surveys across NHS
Recommendation: Patients must be given the opportunity to pass on views on the service which they have received: all parts of the NHS should routinely seek and act on feedback from patients as to their views of the service. In addition, …
Unknown
BRIS-31 — Require trusts to publish periodic reports on patient views and actions
Recommendation: Trusts and primary care trusts must have systems for publishing periodic reports on patients’ views and suggestions, including information about the action taken in the light of them. (See further the Recommendations on care of an appropriate standard.)
Unknown
HIDD-52 — Provide appropriate feedback to drivers reporting signalling irregularities on outcomes
Recommendation: BR shall ensure that drivers, reporting on signalling irregularities, are given appropriate feedback on the outcome.
Unknown
HIA-2 — Memorial at Stormont
Recommendation: We recommend that a suitable physical memorial should be erected in Parliament Buildings, or in the grounds of the Stormont Estate.
Gov response: No formal government response published.
Accepted
Delivered
100 — Posthumous honours forfeiture policy
Recommendation: The Cabinet Office should re-examine the policy on posthumous forfeiture, in order to consider the perspectives of victims and survivors of child sexual abuse.
Gov response: On 30 September 2021, the Cabinet Office updated its guidance in relation to honours forfeiture. The policy allows for a formal statement to be published in instances where forfeiture proceedings would have been initiated if …
Accepted
Delivered
99 — Honours forfeiture for CSA convictions
Recommendation: The criteria for forfeiture of all honours must be formally extended to include convictions, cautions and cases decided by trial of the facts involving offences of child sexual abuse. This must be set out in a published policy and procedure, …
Gov response: On 30 September 2021, the Cabinet Office updated its guidance in relation to honours forfeiture. Anybody convicted of a sexual offence will be considered for forfeiture regardless of the sentence they receive. Anybody found to …
Accepted
Delivered
AC-2d — Structured Response to Community Input
Recommendation: To build confidence that IBCA is actively listening to people infected and affected, IBCA adopt more of a structured response to contributions from people infected and affected. Consideration should be given, as a minimum, to making a contemporaneous record of …
Gov response: The remaining 11 recommendations focus on IBCA delivery. Further detail on these will be set out by IBCA in due course.
Accepted
In progress
IBI-10a(i) — Patient Satisfaction in Clinical Audits
Recommendation: A clinical audit should as a matter of routine include measures of patient satisfaction or concern, and these should be reported to the board of the body concerned. Success in this will be measured by comparing the measure of satisfaction …
Gov response: UK Government The Health Secretary, the Rt Hon Wes Streeting MP, in setting out his mission for saving the NHS earlier this year, stated his aim to return to the “highest patient satisfaction in history”. …
Accepted
In progress
IBI-10a(v) — Yellow Card System Prominence
Recommendation: Steps be taken to give greater prominence to the online Yellow Card system to those receiving drugs or biological products, or who are being transfused with blood components.
Gov response: The online Yellow Card system is UK wide and therefore this recommendation has been addressed on a UK wide basis. The Yellow Card system has provided vital feedback, but we agree with the inquiry that …
Accepted
In progress
IBI-2a — UK and Devolved Memorials
Recommendation: A permanent memorial be established in the UK and consideration be given to memorials in each of Northern Ireland, Wales and Scotland. The nature of the memorial(s), their design and location should be determined by a memorial committee consisting of …
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
In progress
IBI-2b — Treloar's School Memorial
Recommendation: A memorial be established at public expense, dedicated specifically to the children infected at Treloar’s school. The memorial should be such as is agreed with those who were pupils at Treloar’s.
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
In progress
IBI-7e — Implementing SHOT Reports
Recommendation: Implementing SHOT reports: That all NHS organisations across the UK have a mechanism in place for implementing recommendations of Serious Hazard of Transfusion (SHOT) reports, which should be professionally mandated, and for monitoring such implementation.
Gov response: UK Government Work is underway to develop governance practices for the implementation of SHOT recommendations, with careful consideration given to the needs for standardisations and the needs of local organisations. Accreditation for SHOT as an …
Accepted in Part
In progress
IBI-9b — Trust/Board Action on Peer Reviews
Recommendation: That NHS Trusts and Health Boards should be required to deliberate on peer review findings and give favourable consideration to implementing the changes identified with a view to ensuring comprehensive, safe, care.
Gov response: UK Government Recommendation 9a-9c: Peer review of UK comprehensive care centres has been an essential part of haemophilia services for many years. The triennial audit was replaced in 2019 with a more formal peer review …
Accepted
In progress
IBI-A-2e — Transparency of Scheme Design
Recommendation: The Government and IBCA establish a mechanism by which individuals or organisations may raise concerns which arise about any aspect of the scheme which from time to time is troubling them. The mechanism is intended to help continuous improvement of, …
Gov response: The Inquiry was clear that there is a need for greater transparency, involvement and listening with the community in remedying injustice by the state. The Government accepts that, together with IBCA, it makes available a …
Accepted
In progress
LADB-17 — Develop a blame-free culture for safety information communication in industry
Recommendation: The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Unknown
LADB-89 — HSC to review compliance with recommendations and publish review outcomes.
Recommendation: A review of compliance with the above recommendations should be conducted on behalf of the HSC within six months of publication of this report, and further reviews should be put in hand as necessary thereafter. The HSC should publish the …
Unknown
MAI-112 — Give consideration to NHS commissioner recommendations
Recommendation: The Department of Health and Social Care should give urgent and close consideration to any recommendations made by the trusts and the NHS commissioners.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
F113 — Complaints handling
Recommendation: The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F12 — Fundamental standards of behaviour
Recommendation: Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F151 — Complaints to MPs
Recommendation: MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F158 — Training and training establishments as a source of safety information
Recommendation: The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, …
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
F159 — Training and training establishments as a source of safety information
Recommendation: Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F198 — Measuring cultural health
Recommendation: Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such …
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
13 — Improve complaints handling
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
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
RHI-35 — Early Warning Systems
Recommendation: Better systems are needed for spotting early warnings and concerns from the public and businesses that something unexpected could be happening or going wrong with an initiative. Simply updating existing complaints and whistle-blowing policies, although helpful, will not be sufficient, …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
PFD Reports (29)
David Heffer
Concerns: The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.
Responded
Etta-Lili Stockwell-Parry
Concerns: The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Responded
Sarah Cunningham
Concerns: Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public transport use by impaired individuals.
Responded
Derek Cole
Concerns: The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from significant events, delaying critical internal reviews.
Responded
Brian Kneale
Concerns: Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Responded
Eden Street
Concerns: Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Responded
Arlo Lambert
Concerns: The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.
Responded
Thomas Ithell
Concerns: The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.
Responded
Samuel Parkin
Concerns: Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Responded
Christine Cumbers
Concerns: The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future reoccurrences.
Responded
Mared Foulkes
Concerns: The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.
Responded
Mohammed Salam
Concerns: The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.
Responded
Michael Jaggs
Concerns: An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.
Responded
Anne Bradley
Concerns: Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.
Overdue
John Berrow
Concerns: An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.
Responded
Ruben Bousquet
Concerns: Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.
Overdue
Wendy Wilkes
Concerns: The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.
Responded
Patricia McAdam
Concerns: The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.
Overdue
Darren King
Concerns: There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
Overdue
Andrew Wing
Concerns: A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for accurate diagnosis.
Overdue
Ffion Jones
Concerns: The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.
Overdue
Roger Neaves
Concerns: Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.
Overdue
Edward Lundy
Concerns: Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP trainees were identified.
Overdue
Venkata Kagga
Concerns: Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for paediatric assessment and compliance were not followed, exacerbated by poor information sharing across services.
Overdue
Raymond Davidson
Concerns: Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.
Overdue
Scott Hooper
Concerns: Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.
Overdue
Gary Richards
Concerns: Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.
Responded
Garrett Joseph Franklin Elsey
Concerns: An important HSE safety document concerning people in commercial waste containers is not widely known within the industry, indicating a need for an alert system to ensure awareness.
Pending
Stanley Dobson
Concerns: Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
Response: The Department of Health explicitly rejects the suggestion of establishing national staffing ratios for care homes, stating it is not practical and there is no intention to add them to …
Pending