Feedback not integrated
Failure of service providers to systematically collect and integrate feedback from staff, service users, and relatives to inform improvements.
37 items
1 source
12 inquiries
Source spread
Where this theme appears
Feedback not integrated has been flagged across 1 independent accountability source:
37 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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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 (37)
R47 — Quarterly family feedback via external agency
Recommendation: The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency and report the findings to the public part of a Board-level committee minutes (where these exist) and publish …
Response Pending
R46 — Lived experience feedback via external agency
Recommendation: Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and behaviours on a quarterly basis through an external and independent agency (perhaps to be undertaken by the PCC), …
Response Pending
R39 — Guidance on recording and presenting concerns
Recommendation: People with learning disabilities and autistic people and their families should be provided with a short description of how best to record and present concerns so as to be effective.
Response Pending
R38 — Clear pathways for raising concerns
Recommendation: People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for raising concerns. This information should clearly distinguish between an enquiry, a concern and a complaint. Individuals should then …
Response Pending
AFA-1 — Patient focus and complaints
Recommendation: The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication …
Response Pending
R20 — Independent advocacy for service users and families
Recommendation: Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising concerns and complaints. DoH/SPPG should specify the level of advocacy services required for people with learning disabilities in …
Response Pending
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
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
R78 — Audit committee implementation tracking
Recommendation: HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully …
Response Pending
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
No update 2+ yrs
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
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
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
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: Accepted in full
Accepted
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
No update 2+ yrs
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
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
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-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-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-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
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
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
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
No update 2+ yrs
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
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
AC-2c — Community Advisory Body
Recommendation: A formal role be given within IBCA for an advisory body consisting of people infected and affected, covering a range of experience broadly representative of those groups, and (if those groups so wish) including clinicians covering the major relevant disciplines …
Gov response: The remaining 11 recommendations focus on IBCA delivery. Further detail on these will be set out by IBCA in due course.
Accepted
No update 2+ yrs
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
No update 2+ yrs
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
No update 2+ yrs
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
No update 2+ yrs
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
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
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
No update 2+ yrs
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
No update 2+ yrs
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
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