Healthcare Professional Suicide Risk
High suicide rate among health service professionals, particularly GPs, indicating a need for greater awareness and preventative action.
140 items
15 sources
5 inquiries
Source spread
Where this theme appears
Healthcare Professional Suicide Risk has been flagged across 15 independent accountability sources:
7 inquiry recs
35 PFD reports
26 committee recs
7 HMICFRS recs
4 PPO recs
2 IOPC recs
2 PHSO recs
1 VC rec
13 IMB reports
21 IMB recs
1 Scottish FAI
1 Article 2 learning point
3 detention investigation recs
5 PHSO decisions
12 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (7)
COVID-M3.10 — Healthcare Worker Support
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should …
Gov response: No formal response published by this government.
Unknown
COVID-M3.8 — Recording Healthcare Worker Deaths
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in …
Gov response: No formal response published by this government.
Unknown
R36 — Medical staffing levels
Recommendation: Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high-quality care.
Gov response: Section 4.1 of the Scottish Government's response addresses the need for appropriate levels of medical staff to provide safe, high-quality care. It states a full commitment to planning an NHS workforce that delivers high-quality services, …
Accepted
SP35 — Balancing vulnerability with professional curiosity
Recommendation: Counter Terrorism Policing Headquarters should review and where necessary strengthen the training that Counter Terrorism officers involved in Prevent already receive to ensure that they understand the importance of balancing concern for an individual’s vulnerability with appropriate professional curiosity and …
Response Pending
SP34 — Neurodiversity training for Prevent practitioners
Recommendation: Counter Terrorism Policing Headquarters should review its neurodiversity training for Prevent practitioners (including, where appropriate, drawing in wider healthcare advice) to ensure that they sufficiently equip practitioners with a proper understanding of: 1. How autism may influence risk in the …
Response Pending
BRIS-103 — Royal College of Surgeons to develop training and explore surgeon age limits
Recommendation: The Royal College of Surgeons of England should, in partnership with university medical schools and the NHS, be enabled to develop its unit for the training of surgeons, particularly in new techniques. It should also explore the question of whether …
Unknown
4 — Establish continuing professional development requirements
Recommendation: Following completion of additional training or experience where necessary, the University Hospitals of Morecambe Bay NHS Foundation Trust should identify requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation. This should be completed …
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
PFD Reports (35)
Ishmail Kubilay
Concerns: The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.
Overdue
John Davies
Concerns: GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal or self-harming behaviours.
Overdue
Lee Gaunt
Concerns: The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's death, indicating a general lack of support for staff in stressful situations.
Response (Lee Gaunt): GMFRS has amended its procedures to allow employees to self-refer for counselling via its occupational health provider. It has also been piloting a system known as Trauma Risk Management (TRiM) …
Responded
Laura McRory
Concerns: The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan on discharge and deficiencies in the internal investigation.
Response (North East London NHS Foundation Trust): The Trust states it has carefully considered the report and is fully cognisant of the issues and committed to continuously review its service and has enclosed the Trust's action plan …
Responded
Charlie Craig
Concerns: British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.
Response (British Cycling): British Cycling will implement new cardiac screening guidelines developed with Liverpool John Moores University for all athletes on the World Class Programme and apprentice level. Apprentice riders will not be …
Responded
Terence Thornton
Concerns: Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.
Response (University Hospitals Plymouth NHS Trust): Following an incident, the Consultant Neuroradiologist submitted the case for review, it was discussed at a departmental discrepancy meeting and lessons were shared with the Radiology team.
Overdue
Nathan Mooney
Concerns: The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Response: Health Education England acknowledges the challenges of recruiting and retaining doctors. They mention a commitment to increasing medical school places and the development of a workforce implementation plan to address …
Responded
Joshua Blackham
Concerns: Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.
Response (Surrey Police): Surrey Police will provide training and refreshed guidance for Welfare Officers and those who supervise them. Revised guidance has been created to include contacting the family of an officer suspended …
Responded
Carl Sargeant
Concerns: The report highlights a need to provide appropriate support channels for high-profile individuals removed from government roles, regardless of mental vulnerabilities or the reason for their removal.
Response (Welsh Government): The First Minister of Wales has consulted with current and former ministers and the family of the deceased to make changes to the process for ministers leaving the Cabinet. A …
Responded
Shaun Dewey
Concerns: The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
Response (HM Prison and Probation Service): HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks …
Responded
Madhavbhai Patel
Concerns: A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for their cultural diet and eating practices.
Response (Walsall NHS Trust): Walsall NHS Trust is implementing changes to improve patient safety related to choking risks, including staff training on IDDSI standards by June 2020, replacing patient documents with IDDSI materials by …
Responded
Jaden Francois-Espirit
Concerns: The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.
Response (London Fire Brigade): LFB accepted all 24 recommendations in the investigation report following the death of Jaden Francois-Esprit, and created an action plan, extended to include the coroner's concerns, with a total of …
Responded
Helen Spicer
Concerns: Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about opioid overuse and misuse. They outline actions taken, including a PHE evidence review, front-of-pack warnings on opioid medications, and structured …
Response (ACMD): The ACMD acknowledges the concerns and will gather more information on the scale of the issue of morphine sulfate solution misuse, being mindful of its legitimate use. They will request …
Responded
Kelly Hewitt
Concerns: There is an inadequate provision of mental health support for prison officers, which needs urgent review.
Response (HM Prison and Probation Service): HMPPS employs an Employee Psychological Support Services Clinical Lead. They launched a staff suicide prevention campaign, "Reach Out, Saves Lives" in September 2020, and are working with Remploy to provide …
Responded
Khairul Rahman
Concerns: The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Response (Practice Plus Group): Practice Plus Group has begun a service improvement project to encourage the appropriate use of NEWS2 scoring and embedding this into practice, including a ‘Back to Basics’ workshop on ‘Identifying …
Overdue
Sarah-Louise Doyle
Concerns: Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.
Response (Mersey Care NHS Foundation Trust): The Trust has already taken actions, including issuing urgent instructions on recording intermittent observations, discussing the report at safety huddles, ensuring competency updates for staff, conducting spot checks on observation …
Overdue
Billy Longshaw
Concerns: The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.
Overdue
James Forryan
Concerns: Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.
Response (Department of Health and Social Care): The Department of Health and Social Care is taking steps to protect users online with the Online Safety Bill, working with stakeholders to remove harmful suicide and self-harm content. They …
Responded
Susan Carling
Concerns: High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.
Response (Department of Health and Social Care): The Department highlights resources such as Practitioner Health for healthcare workers and mentions national efforts to prevent suicide, including the cross-government strategy and investments in local prevention plans and bereavement …
Response (Royal College of General Practioners): The RCGP acknowledges the issue of suicide among health professionals and details the support and resources available, including Practitioner Health, The Doctors' Support Network, HHP Wales and the Sick Doctors …
Responded
Neil McDougall
Concerns: Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.
Response (Ministry of Defence): The Army has current policies and procedures to minimise the risk of suicide within the ranks of serving military personnel and the veteran community including education to tackle stigma, providing …
Responded
Lee Winslow
Concerns: The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when he continued private practice. A critical lack of multi-disciplinary review, relying on the medical hierarchy, was noted given the gravity and prior similar cases.
Response (Manchester University NHS Foundation Trust): The Trust believes the coroner's concerns were already addressed during the inquest and in prior correspondence. While noting collaborative work among Greater Manchester Medical Directors, it suggests a national-level review …
Responded
Kyriacos Athanasis
Concerns: Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks and delayed diagnosis of severe injuries.
Response (Department of Health and Social Care): The Department of Health and Social Care outlines national initiatives to improve urgent and emergency care, including the Delivery Plan for Recovering Urgent and Emergency Care Services, aiming for faster …
Response (Norfolk and Waveney Integrated Care Board): The Integrated Care Board outlines plans to improve the urgent and emergency care system, including developing a virtual ward, an urgent community response service, and urgent treatment centres. The UEC …
Responded
Lyn Brind
Concerns: Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading to insufficient patient monitoring and significant ambulance handover delays.
Response (Department of Health and Social Care): The Department of Health and Social Care highlights the 'Delivery plan for recovering urgent and emergency care services', investments in virtual wards, and the Discharge Fund to improve patient flow …
Responded
Stephen Chapple and Jennifer Chapple
Concerns: The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly given the potential for recipients to have mental health issues from combat service.
Response (Ministry of Defence): The MOD has written to the Service Chiefs to remind them of their duty to ensure that misappropriation of MOD items is identified and investigated. The issue of potentially lethal …
Responded
Robert Stevenson
Concerns: Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to increase awareness and mitigate this risk.
Overdue
Barry Lall
Concerns: The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who are contesting them.
Response (General Dental Council): The GDC is undertaking a review of its policy on publishing Interim Order determinations and holding hearings in public, aiming to balance public interest with the interests of the registrant, …
Responded
Gina Bywater
Concerns: Persistent and severe ambulance non-availability in the East of England led to nearly 10-hour delays. Expert evidence indicates that prompt ambulance arrival and early treatment could have saved the patient's life.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the concerns and outlines actions being taken by NHS England and EEAST to improve ambulance response times, including increased recruitment, clinical triage …
Responded
Christopher Hart
Concerns: Persistent and significant ambulance non-availability in the East of England region led to extreme delays, where prompt arrival and early treatment could have saved a patient's life.
Response (Department of Health and Social Care): The Department of Health and Social Care notes that East of England Ambulance Service NHS Trust (EEAST) is implementing an Operational Performance and Improvement Plan to improve efficiency and maximise …
Responded
Ruth Perry
Concerns: Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or clear channels for raising concerns. Local authority support also lacks formal policy.
Response (Ofsted): Ofsted has taken action to ensure inspectors are aware of the support available to school leaders, reinforcing the expectation that they share this information at the beginning of an inspection …
Response (Department for Education): The Department for Education will write to all Responsible Bodies setting out their responsibilities and committing to working closely with local authorities and academy trusts to ensure school leaders are …
Response (Reading Borough Council): Reading Borough Council, through Brighter Futures for Children Ltd, has consulted with head teachers and will proactively challenge Ofsted inspections on a school's behalf. They have already written to school …
Responded
Benjamin Sulzbacher
Concerns: Priory staff lacked understanding of NHS community services available upon discharge. It was also unclear whether private-paying inpatients could access NHS discharge services, which offer more extensive community support and face-to-face contact.
Response (Benjamin Sulzbacher Prevention of Future Deaths Report and Responses 2024): The Department says that patients should not lose their right to access NHS services by accessing private services, and that NHS England has signposted relevant guidance to ICBs. The Priory …
Overdue
Anugrah Abraham
Concerns: Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.
Response (West Yorkshire Police): West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National …
Response (College of Policing and National Police Chiefs Council): The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also …
Responded
John McLoughlin
Concerns: Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of robust mental health support for escalating problems within the industry.
Response (Civil Aviation Authority): The Civil Aviation Authority will instruct inspectors to encourage operators and Approved Training Organisations to improve mental health support to pilots, including upskilling peer supporters and supporting escalation of concerns …
Overdue
Wayne Brown
Concerns: The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
Response (West Midlands Fire Service): West Midlands Fire Service will review the level and nature of support provided to senior officers undergoing a disciplinary process, including specific provisions within its Health and Wellbeing Policy, and …
Responded
Steven Davidson
Concerns: Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Response (HCRG Care Group): HCRG Care Group has amended its training provision so that all new staff receive structured SystmOne training as part of their induction and will provide refresher training to existing staff …
Responded
Benjamin Websdale
Concerns: There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented trauma education campaigns.
Response (National Police Chiefs Council): • The NPCC has been collating near real time suspected suicide surveillance data since January 2022, facilitated through the NPCC Suicide Prevention Steering Group and formulated from data returns provided …
Responded
Committee Recommendations (26)
#17 —
Recommendation: Covid-19 has exacerbated existing problems with staff welfare, but also brought some benefits, including higher levels of recognition and different ways of working. While enhanced recognition of the work of health and care staff is welcome, adequate and holistic support …
Gov response: 4.1 We recognise the impact the COVID-19 pandemic may have over the longer term and are committed to monitoring its effect on the workforce to ensure we respond to any arising needs. 4.2 In the …
Under Consideration
#69 —
Recommendation: Alastair Sim, Director of Universities Scotland, told the Committee that the pandemic had also “been an incredibly difficult time for staff”.160 Dr Vicky Johnson stated that: [ … ] a lot of the senior management teams [ … ] are …
Not Addressed
#1 —
Recommendation: Burnout is a widespread reality in today’s NHS and has negative consequences for the mental health of individual staff, impacting on their colleagues and the patients and service users they care for. There are many causes of burnout, but chronic …
Gov response: 2.1 Recommendation 1 and 2 have been grouped together for an overarching response to the committee. 2.2 The government agrees with the committee that monitoring staff wellbeing is essential both to better understand the various …
Under Consideration
#19 —
Recommendation: The mental health of farmers is one of the biggest challenges currently facing the sector. In October 2021, the Royal Agricultural Benevolent Institution reported that almost half of the farming community (47%) were experiencing some form of anxiety, and 36% …
Gov response: 6: PAC conclusion: We are not doing enough to support farmers through the transition to the new schemes and alleviate any anxiety its plans are causing. 6: PAC recommendation: The Department should identify what further …
Not Addressed
#21 —
Recommendation: The Government must introduce a dedicated, trauma-informed health pathway for all those affected by historical forced adoption. This should include improved access to specialist psychological support for birth mothers and adult adoptees, national clinical guidance recognising the heightened prevalence of …
Response Pending
#19 — Increase mental well-being support for prison staff, building on existing services.
Recommendation: HMPPS should build on its existing management guidance and occupational health services to increase its support for the mental well-being of those who work in prisons.
Gov response: The Government agreed that we should end the use of prison as a place of safety for individuals with severe mental health issues in the Mental Health Act White Paper and committed to legislating at …
Under Consideration
#10 —
Recommendation: We further recommend that the Department of Health and Social Care work with stakeholders to develop staff wellbeing indicators, on which NHS bodies can be judged.
Gov response: 3.7 As detailed in recommendation 2, the annual NHS Staff Survey provides a key indication of staff wellbeing across NHS Trusts. The new Wellbeing Dashboard incorporates relevant questions from the staff survey alongside other measures …
Under Consideration
#101 —
Recommendation: We are concerned by the reports we heard about the impacts of fatal shootings which take place in rural communities in Scotland. It is clear to us that these communities should be provided with appropriate support where needed.
Gov response: The UK Government has noted the Committee’s recommendation in relation to advertising avenues to mental health support for the shooting community and also the points made about the particular challenges faced by rural communities traumatised …
Accepted
#100 —
Recommendation: However, in relation to specific incidents, Reverend Gordon Matheson told us that “[t]here are issues around the subsequent trauma that people have experienced and accessing counselling care for that”.238 This issue is compounded by the relative lack of policing and …
Gov response: The UK Government has noted the Committee’s recommendation in relation to advertising avenues to mental health support for the shooting community and also the points made about the particular challenges faced by rural communities traumatised …
Under Consideration
#9 —
Recommendation: The withdrawal from Afghanistan and end of the UK’s twenty-year military involvement in the country has understandably had a negative impact on veterans’ mental health. This has increased demand on services provided by organisations such as Combat Stress and Help …
Gov response: The Government is committed to the support and promotion of positive mental wellbeing for the whole Defence community, including veterans. Lead responsibility for the provision of veteran healthcare is led by the Department for Health …
Accepted
#7 — Create clear objectives and actions for agricultural and veterinary workers in national suicide prevention strategy
Recommendation: We are very concerned by the evidence indicating that agricultural and veterinary workers have a higher-than-average suicide rate compared to the rest of the population. Although more accurate information is needed, a clear enough picture Rural Mental Health 77 was …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Accepted
#6 — Joined-up public health approach essential for preventing suicide among agricultural and veterinary workers
Recommendation: Adopting a more joined-up approach to public health focused on early intervention could make a positive contribution to preventing suicide amongst agricultural and veterinary workers. It would need to ‘wrap-around’ people at potential risk, incorporating the NHS, other key public …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Not Addressed
#5 — Require DEFRA to establish a clear and active role in national suicide prevention strategy
Recommendation: DEFRA should be an active stakeholder in any national suicide prevention strategy, as the Department is responsible for populations and occupational groups arguably at higher-than-average risk of poor mental health and death by suicide. However, DEFRA does not appear to …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Not Addressed
#4 — Addressing risks and stressors for farming and veterinary workers represents an immediate priority.
Recommendation: In particular, the long list of risks and stressors affecting the farming community and veterinary workers is perhaps the immediate priority, not least because there are real opportunities for substantial gains in this area with significant levers for change in …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Accepted
#27 — Review and strengthen support mechanisms for school leaders' wellbeing during and after inspections.
Recommendation: The Department and Ofsted should review the support mechanisms available to school leaders during and following an inspection and ensure that these are as strong as possible to support the wellbeing of school leaders. Ofsted must publish a clear policy, …
Gov response: We recognise that inspection and regulation can sometimes be challenging for providers, and we welcome the Committee’s focus on the mental health and well-being of those we inspect and regulate. We share a determination to …
Accepted
#25 — High-stakes inspection system causes significant stress and job insecurity for school leaders.
Recommendation: The ‘high-stakes’ nature of the current system is clearly causing a significant amount of stress and worry for school leaders. In particular, there is an overwhelming fear among headteachers that they risk losing their job following a less than ‘good’ …
Gov response: Many of the recommendations in the Committee’s report fall to the DfE, rather than Ofsted. We will engage with the DfE on inspection grades (Recommendation 14), on ensuring the consequences of inspection are proportionate (Recommendation …
Not Addressed
#17 — Existing data underscores the urgent need to improve support for terminally ill individuals.
Recommendation: We are pleased that the ONS in now attempting to monitor the rates of suicide for people with a terminal diagnosis, as this will facilitate scrutiny in the future. The existing data already serves as a sobering reminder that the …
Not Addressed
#16 — Committee expresses deep sadness over experiences of loved ones taking their own life.
Recommendation: We were extremely saddened to read and hear about the experiences of people who had experienced a loved one taking their own life, and our thoughts and deepest sympathies remain with them.
Not Addressed
#27 —
Recommendation: By October 2020, employers had reported 8,152 diagnosed cases of COVID-19 and 126 deaths as being linked to occupational exposure among health and care workers.45 The British Medical Association and Unison asserted that the Department should investigate whether PPE shortages …
Gov response: 5.5 There are mechanisms in place to investigate the deaths of health and care workers which involve coroners and the Health and Safety Executive (HSE). Medical examiners also have a role in scrutinising deaths of …
Not Addressed
#56 —
Recommendation: The Foreign, Commonwealth and Development Secretary said the looting of health centres and destruction of vital infrastructure by Eritrean forces and other belligerents had led to “the disintegration of essential basic services and is exacerbating the parlous humanitarian context.”132 He …
Gov response: The UK will work through the multilateral system, in partnership with other donors, to address the restoration of basic services drawing on experience from other crises. At present the level of insecurity means that basic …
Not Addressed
#52 —
Recommendation: Dr Christian Rogg, the FCDO’s Development Director for Ethiopia, echoed CARE International’s findings, telling us that most healthcare facilities were not functioning. He said restoring services would be challenging because facilities had been looted and personnel had left leading to …
Gov response: The UK will work through the multilateral system, in partnership with other donors, to address the restoration of basic services drawing on experience from other crises. At present the level of insecurity means that basic …
Not Addressed
#50 —
Recommendation: People in Tigray have very little access to healthcare.115 Hospitals, health facilities, medical supplies and ambulances have been looted. Médecins Sans Frontières (MSF) estimated that barely 1 in 10 health facilities were functioning; of the 106 health facilities MSF teams …
Gov response: The UK will work through the multilateral system, in partnership with other donors, to address the restoration of basic services drawing on experience from other crises. At present the level of insecurity means that basic …
Not Addressed
#10 —
Recommendation: We recommend a more precautionary approach is taken and a greater proportion of the money spent on elite sport is focussed on protecting the athletes who are at the core of UK success in sporting endeavours. We also recommend that …
Gov response: The Government agrees in part with this recommendation. The Government believes that the welfare of athletes should be of paramount importance, and that sports in receipt of public funding should look to lead the way …
Under Consideration
#15 —
Recommendation: The evidence we have taken leaves us in no doubt about the seriousness of the issues facing the food and farming sector caused by labour shortages. These include food security, animal welfare and the mental health of those working in …
Gov response: The Government thanks the committee for its report into labour shortages in the food and farming sector. We welcome the opportunity to present a joint Home Office and Defra response to the report’s recommendations. It …
Not Addressed
#7 — Mental health workforce experiences increased burnout and turnover due to staff shortages
Recommendation: We were also concerned about the impact of staff shortages on the welfare of the mental health workforce. Stakeholders told us about increased workload and pressure leading to “burnout” of remaining staff, contributing to a higher rate of staff turnover, …
Gov response: 1.1 The government agrees with the Committee’s recommendation. Target implementation date: January 2024 1.2 The NHS Long Term Workforce Plan, published on 30 June 2023, considers the challenges facing the NHS workforce over the next …
Accepted
#31 —
Recommendation: We have heard distressing evidence on the effects on the mental health of people silenced by a non-disclosure agreement. The Government should consider the potential merits of a retrospective moratorium on NDAs for those that have signed them relating to …
Gov response: We support this recommendation to ensure individuals can freely discuss their experience and concerns to us, helping us to build a clear picture of what is happening across the music industry and wider creative industries.
Not Addressed
HMICFRS Recommendations (7)
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Avon FRS isn’t looking after the wellbeing and mental health of its staff effectively. It hasn’t clearly communicated to staff the new values and how to demonstrate these values in the workplace. Recommendation: By 30 June 2019, …
Recommendation
PEEL 2021-22 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police doesn’t currently have the arrangements in place to support and build its workforce. Recommendation: Within six months Greater Manchester Police should work with its workforce to understand the risks and threats to staff wellbeing, …
Recommendation
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Avon FRS isn’t looking after the wellbeing and mental health of its staff effectively. It hasn’t clearly communicated to staff the new values and how to demonstrate these values in the workplace. Recommendation: The service should assure …
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force doesn’t manage the risk posed by online child abuse offenders effectively. Recommendation: Immediately, West Midlands Police should make sure that it supports the online child sexual exploitation and digital forensic unit teams’ well-being.
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force doesn’t manage the risk posed to the public by registered sex offenders effectively. Recommendation: Immediately, West Midlands Police should it supports sex offender managers’ well-being.
Recommendation
PEEL 2018-19 CoC Recommendations: Nottinghamshire Police
Cause of concern: We are concerned that Nottinghamshire Police does not consistently support the wellbeing of its workforce. The force has a wellbeing strategy in place, but has not made enough progress to promote it and create a culture where …
Recommendation
PEEL 2018-19 CoC Recommendations: Nottinghamshire Police
Cause of concern: We are concerned that Nottinghamshire Police does not consistently support the wellbeing of its workforce. The force has a wellbeing strategy in place, but has not made enough progress to promote it and create a culture where …
Recommendation
PPO Death in Custody Recommendations (4)
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff adhere to NICE Guidance [NG28] for patients presenting with raised blood glucose levels.
The Head of Healthcare at HMP Berwyn
The Head of Healthcare should ensure that: appropriate measures are put in place to offer support to healthcare staff following their involvement in significant incidents.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff involved in a death in custody, and those that are identified as significant to the deceased, should be offered support in line with Postvention procedures.
The Governor of HMP Whatton
The Governor should ensure that staff receive adequate support following a death in custody.
IOPC Learning Recommendations (2)
Police investigation into serious sexual offences – Cambridgeshire Constabulary, July 2019
The IOPC recommends that Cambridgeshire Constabulary takes steps to ensure that sufficient wellbeing and welfare support are in place for officers and staff working in the Paedophile Online Investigation Team (POLIT). This should include considering: This follows an IOPC investigation …
Recommendation - Avon and Somerset Constabulary, February 2025
The IOPC recommends that Avon and Somerset Constabulary take steps to ensure officers carrying out voluntary attendance interviews can access relevant guidance and support on suspect management, in particular how to mitigate the risk of self-harm and suicide in cases …
PHSO Ombudsman Recommendations (2)
Ignoring the alarms: How NHS eating disorder services are failing patients
Health Education England should review how its current education and training can address the gaps in provision of eating disorder specialists we have identified.
Ignoring the alarms: How NHS eating disorder services are failing patients
The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.
Victims' Commissioner Recommendations (1)
IMB Annual Reports (13)
Isle of Wight (2023)
HMP Isle of Wight's population rose to 1,089 in 2023, operating at near capacity. The prison experienced a rise in deaths in custody (13) and violent incidents (191), although self-harm decreased. Key challenges included aging infrastructure, high staffing vacancies in OMU and healthcare, and inconsistent regime delivery for older prisoners, while positive developments were noted in education and integrated mental health services.
PRISON
Key concerns
Garth (2023)
HMP Garth, a Category B training prison, generally provides a safe environment, though self-harm and violence incidents increased. The Board's key concerns include persistent staff shortages impacting regime stability, key worker schemes, and offender management. The prison's physical estate is in poor condition, and delays in mental health transfers for complex cases remain critical. The IMB highlights the ongoing challenges of the IPP sentence and issues with prisoner progression and property transport.
PRISON
Key concerns
Gatwick IRC (2023)
The Gatwick IRC experienced a deterioration in safety during 2023, marked by increased violence, assaults on staff, and a rise in use of force incidents, partly attributed to a changing detainee population. Key safeguards for vulnerable individuals, such as Rule 34 and Rule 35 assessments, were found to be insufficient or subject to unacceptable delays. The report highlighted significant concerns regarding inadequate mental health provision, unfair regime practices including prolonged lock-in times, and a lack of effective pathways for release for detainees granted bail.
IRC
Key concerns
Liverpool (2023)
HMP Liverpool has shown positive progress in some areas, including education and the key worker scheme, but faces significant challenges. The Board is concerned by increases in self-harm, violence, and deaths in custody, compounded by high staff absence leading to regime closures. Major issues include inhumane delays in mental health transfers for segregated prisoners and a critical lack of accessible accommodation for those with disabilities.
PRISON
Key concerns
Leeds (2023)
HMP Leeds, a Category B local prison, faced significant challenges in 2023, particularly regarding overcrowding, which impacted shared cell conditions, and a concerning number of deaths in custody. The Board highlighted persistent issues with mental health provision, including transfer delays and a lack of secure beds, alongside ongoing concerns for IPP prisoners' progress and wellbeing. Staffing shortages and inexperience also posed challenges, affecting prisoner reception and key worker continuity, although efforts to improve training and staff-prisoner relationships in specific units were noted.
PRISON
Key concerns
Heathrow immigration removal centre (2023)
The IMB report for Heathrow IRC (2023) highlights increasing safety concerns, including a rise in self-harm (180 incidents), assaults (131 detainee-on-detainee, 54 on staff), and drug finds (104). The Board expresses significant concerns over the detention of mentally unfit individuals, the dilapidated infrastructure, and the misuse of segregation units. While health needs are generally met, staffing shortages and delayed Rule 35 responses remain problematic. The report also notes repeated concerns about prolonged detention times and the need for improved resettlement pathways for those on bail.
IRC
Key concerns
Lewes (2023)
HMP Lewes continues to face severe challenges, primarily driven by staff shortages that restrict the regime, leaving many prisoners out of cell for only an hour a day. This has contributed to significant increases in self-harm and assaults on staff, while issues with healthcare provision, mental health support, and the decency of accommodation persist. The Board highlights the disproportionate use of force against BAME prisoners and the ongoing lack of resettlement support for those on remand.
PRISON
Key concerns
Lancaster Farms (2023)
HMP Lancaster Farms, a category C resettlement prison, has largely provided a safe environment, though some pandemic regime restrictions were slow to lift. While primary healthcare is reasonable, mental health provision faces significant challenges due to staffing and a lack of specialist transfer capacity. Key worker contact and prisoner property management remain ongoing concerns for the Board, alongside issues of cell decency and delayed purposeful activity opportunities.
PRISON
Key concerns
Hewell (2023)
HMP Hewell, a Category B reception prison, faced severe overcrowding in the reporting year, with its population increasing to 1,060 and many prisoners sharing cells designed for one. This contributed to a significant rise in self-harm incidents and a persistent, restricted regime where most men are locked in cells for 22 hours daily. The report highlights ongoing challenges with staff shortages, inadequate key worker training, and delays in mental health transfers, alongside concerns about resettlement provision and the unmet needs of neurodiverse prisoners.
PRISON
Key concerns
Foston Hall (2023)
HMP/YOI Foston Hall has shown positive developments in regime provision and some safety initiatives, yet it continues to grapple with persistently high self-harm rates and increased use of force. Staffing shortages have impacted key work and overall experience levels, while healthcare faces challenges with recruitment, missed appointments, and inadequate facilities. The Board highlights significant concerns regarding accommodation decency, delays in parole and mental health transfers, and a lack of analytical focus on protected characteristics, affecting fair treatment and access to services.
PRISON
Key concerns
Full Sutton (2023)
HMP Full Sutton, a Category A and B high-security prison, operated with a population of 584 against an operational capacity of 594 at the end of 2023. The Board found it generally calm and well-managed, but tight staffing levels led to widespread rotational lockdowns, impacting purposeful activity and time out of cell. Key concerns include increased self-harm and violence, reduced drug testing capacity, and insufficient work opportunities, alongside delays in property distribution and a psychologist shortfall.
PRISON
Key concerns
Portland (2020)
HMP/YOI Portland, a Category C prison, faced significant challenges in delivering a stable daily regime, with frequent shutdowns impacting education and activity opportunities. While prisoner-on-prisoner assaults reduced slightly, overall violence remained high, and the prison struggled with drug ingress and staff shortages in mental health services. The Board noted concerns regarding poor building maintenance, staff attitudes towards prisoners, and issues with property transfers.
PRISON
Key concerns
Chelmsford (2021)
HMP/YOI Chelmsford, a Category B local prison, faced significant challenges during a reporting year heavily impacted by COVID-19 restrictions, leading to a restricted regime with limited purposeful activity and prolonged cell confinement. Key concerns included persistent overcrowding, a severe rat infestation, and substantial delays in handling prisoner complaints and property issues. The prison also struggled with staffing shortages, particularly affecting the key worker scheme and healthcare provision, alongside high self-harm rates and increased assaults on staff.
PRISON
Key concerns
IMB Recommendations (21)
Moorland (2022)
Can the minister ask cabinet colleagues in the Department of Health and Social Care and the Treasury to address this shortage of beds?
Ministry of Justice
Low Newton (2022)
The Minister should report on progress to increase the number of places available nationally in secure psychiatric units, since it remains the case that some women are being placed inappropriately in prison.
Ministry of Justice
Berwyn (2020)
Healthcare representatives at good reviews
NHS / Healthcare Provider
Swaleside (2022)
The Board is extremely concerned at the continuing low numbers of staff and the seeming inability to recruit. The inequality of pay and conditions when compared to other government agencies is certainly a factor in the cause of this issue together with the accessibility of the geographical area in which the prison is situated. The low numbers of staff severely …
HMPPS
Leicester (2022)
Is the minister satisfied that there are sufficient secure hospital places to cope promptly with the demand?
Ministry of Justice
Nottingham (2023)
To address, with the health service provider, the issues raised in the provision of health care services, staff shortages and health care complaints.
Governor / Director
Eastwood Park (2024)
Address the serious issue of staff compassion burnout, injuries, and attacks from prisoners during restraints.
HMPPS
Scotland and Northern Ireland short-term holding facilities (STHF) (2025)
Ministers should also mandate that immigration detention procedures at least meet the same standards expected of the police. A particular area in need of improvement is healthcare: Policies and practices: A senior clinician should oversee healthcare policies and practices, approving any departure from standards applied in police custody. This would ensure that practices such as the failure to require routine …
Ministry of Justice
Wymott (2020)
The Board remains concerned about the regular cancellation of prisoner forums, particularly the healthcare forum (see also section 3.4).
Governor / Director
Winchester (2021)
What is the prison service doing to hasten the upgrade to the healthcare bathroom and shower area which should be condemned? This work is very long overdue and the need for it was raised in our last two annual reports. (See section 6.3).
HMPPS
Long Lartin (2024)
Prison staffing: following the changes to profiling towards the end of the year, what further measures are proposed to enable all aspects of the regime to operate across the prison (including healthcare)?
Governor / Director
Gartree (2024)
Since the appointment of a new healthcare provider, the Board is aware that there have been numerous complaints about healthcare provision and the response time for prisoner complaints (this has increased from 20 working days to 60 working days). What measures are in place to ensure an acceptable level of patient care is provided and maintained at Gartree?
HMPPS
Gartree (2024)
The Minister has previously advised that healthcare provision is monitored and reviewed by NHS England Midlands Clinical and Quality Team. Despite numerous requests by the Board, the healthcare provider has steadfastly declined to provide any meaningful quantitative data for monitoring the healthcare provision and benchmark against the community equivalent. Again, we ask the Minister to explain how the Ministry of …
Ministry of Justice
Gartree (2024)
The Board raised questions with the Minister last year about the quality and performance of service providers and remains concerned, particularly with regard to healthcare. So, we ask, again, how the Minister plans to address these issues?
Ministry of Justice
Durham (2025)
How does the Governor intend to ensure that all prisoners involved in UoF are seen by healthcare staff?
Governor / Director
Durham (2025)
How does the Governor intend to ensure that all prisoners involved in UoF are seen by healthcare staff?
Governor / Director
Derwentside (2022)
To introduce routine pregnancy testing for women detained in residential short-term holding facilities.
Home Office
Wealstun (2023)
To consider doing a check of the healthcare complaints process to address concerns relating to delays.
Governor / Director
Huntercombe (2023)
When will the Prison Service urgently replace the part of the healthcare facility that has water ingress and is not a reasonable work area?
HMPPS
New Hall (2025)
Continued strategies to address the increase in number of complaints about the healthcare provision, e.g. plans for the women’s health hub and Practice Plus Group monitoring of health care centre concerns and complaints.
Governor / Director
Erlestoke (2025)
While there has been considerable improvement in the attendance of healthcare at first ACCT reviews; just over one fifth still lack this essential input. How is this to be addressed, especially when reviews occur over weekends?
NHS / Healthcare Provider
Detention Investigations (3)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R4
The SMT at Gatwick IRCs must review arrangements for providing care and support to staff and ensure that they have ready access to a care service they trust. (To be completed within 3 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 16
A best practice forum should be established across IRC healthcare providers.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R28
The centre manager and senior Serco managers should continue to engage at all levels with NHS commissioners and G4S to ensure that concerns about the healthcare provision at Yarl’s Wood are addressed.
Immigration Detention
PHSO Casework Decisions (5)
P-004082 — Oxford Health NHS Foundation Trust
Dr V complains a Trust psychiatrist opened and deleted an email she sent in July 2022, in which she expressed concern about her husband's behaviour and made a plea for help. Dr V also complains about the psychiatrist’s appearance and demeanour at the Inquest.
NHS in England
Sep 2025
P-004514 — A practice in the Gateshead area
Mrs G complains in April 2024, a medical practice in the Gateshead area did not reissue her medication at the previously agreed prescribed dosage, and its receptionist did not allow her to explain she felt suicidal or speak with the practice manager.
NHS in England
Dec 2025
P-004047 — An independent provider in the West Berkshire area
Ms X complains about her care and treatment whilst in custody between April to May 2024. She says that PPG failed to manage her eating disorder causing her to relapse and require hospitalisation.
NHS in England
Sep 2025
P-001805 — South Tyneside and Sunderland NHS Foundation Trust
Mr R complains that while his father was under the Trust's care, Trust staff went to his house and stole his savings. He also complains the Trust intentionally gave his father an overdose to end his life, and about the overall low standard of care.
NHS in England
Feb 2023
P-002564 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss R complains about the behaviour of a nurse who she says acted aggressively, misgendered her and failed to take into account that she is autistic.
NHS in England
Apr 2024
LGO / SPSO Decisions (12)
NIPSO-17293 — South Eastern Health and Social Care Trust
Our investigation found that the South Eastern Trust failed to properly assess the risks faced by a patient, and could have done more to help him before his death.
NIPSO (NI Public Service…
Health & Social Care
May 2021
NIPSO-202003166 — Northern Health and Social Care Trust
A woman complained about the care given to her husband in Antrim Area Hospital in the weeks before his death. We upheld parts of the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
NIPSO-202003845 — Southern Health and Social Care Trust
A man with Crohn’s Disease asked the Southern Trust to provide him with an additional bedroom and bathroom. We found the Trust’s decision to only approve a new bathroom was appropriate.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Apr 2024
PSOW-202309997 — Aneurin Bevan University Health Board
Miss D complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she made to it in July 2023. The Ombudsman found that whilst the Health Board had initially dealt with Miss D’s concerns informally, it subsequently failed to log her concerns as a …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202400640 — Hywel Dda University Health Board
Ms V complained that Hywel Dda University Health Board failed to respond to a complaint she submitted in September 2023. The Ombudsman found that there had been a significant delay in the Health Board responding to the complaint. This caused additional frustration and inconvenience for Ms V. The Ombudsman decided …
PSOW (Public Services Om…
Health
May 2024
PSOW-202502304 — Betsi Cadwaladr University Health Board
Mrs H complained that Betsi Cadwaladr University Health Board failed to respond to a complaint she submitted in January 2025. The Ombudsman found that the Health Board failed to keep Mrs H updated for 5 months of its investigation. This caused additional frustration and uncertainty for Mrs H. The Ombudsman …
PSOW (Public Services Om…
Health
Oct 2025
PSOW-202504133 — Aneurin Bevan University Health Board
Miss A complained about the process in obtaining an autism diagnosis for her daughter and about the delay in receiving a response to her complaint (submitted in September 2024) from the Health Board. The Ombudsman found that the Health Board had failed to respond to Miss A’s complaint in a …
PSOW (Public Services Om…
Health
Oct 2025
PSOW-202101792 — Velindre University NHS Trust
Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained …
PSOW (Public Services Om…
Health
Upheld
Jun 2022
PSOW-202303635 — Betsi Cadwaladr University Health Board
Mr X complained about the lack of any contact or support from Conwy CMHT between June 2022 and February 2023 despite having a care and treatment plan in place. The Health Board accepted that, during this period there was no contact from the CMHT, and there were no care records …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202309096 — Betsi Cadwaladr University Health Board
Mrs D complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint about the care and treatment provided to her father which she made to it in August 2023. The Ombudsman found that the Health Board had failed to issue a complaint response and had …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202202910 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board had performed an operation to remove her mother, Mrs Y’s, knee replacement, and replace it with a temporary implant to aid the treatment of her infected knee, without the facilities to carry out the second stage procedure to fit a permanent …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202202910 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board had performed an operation to remove her mother, Mrs Y’s, knee replacement, and replace it with a temporary implant to aid the treatment of her infected knee, without the facilities to carry out the second stage procedure to fit a permanent …
PSOW (Public Services Om…
Health
Nov 2022