Inaccessible multi-agency patient information
Critical patient information (e.g., 'familiar faces plans') being inaccessible to emergency services due to technology limitations.
176 items
12 sources
4 inquiries
Source spread
Where this theme appears
Inaccessible multi-agency patient information has been flagged across 12 independent accountability sources:
4 inquiry recs
28 PFD reports
13 committee recs
2 CQC actions
1 PPO rec
3 IOPC recs
45 IMB recs
1 Scottish FAI
1 detention investigation rec
12 PHSO decisions
65 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 (4)
F35 — Need to share information between regulators
Recommendation: Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work …
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
LAMI-32 — Ensure single, compatible electronic database for all children and families services
Recommendation: Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or …
Unknown
BRIS-29 — Require trusts to provide clear patient access to information and explanation
Recommendation: NHS trusts and primary care trusts must have systems which ensure that patients know where and to whom to go when they need further information or explanation.
Unknown
DM-20 — HOLMES access for independent panels
Recommendation: All independent panels and inquiries examining police investigations should be given full access to the associated HOLMES accounts at their secure premises when they begin their work.
Gov response: Since 2020, police HOLMES databases have become Cloud-based, making the system accessible for the first time via a corporately managed device for those with the appropriate security clearance and purpose.
Accepted
PFD Reports (28)
Dimitar Shtarbov
Concerns: Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their home countries.
Overdue
Audrey Kelly
Concerns: The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic notes, describing this as a serious lapse in procedures that could lead to future loss of life.
Response (Department of Health2): Stockport CCG is seeking formal assurance from Mastercall regarding processes for new starters and contingency plans when practitioners lack smartcards. They will also work with Mastercall to map and analyze …
Response (Department of Health): Stockport CCG are investigating the attempted access to the patient's record at the time of the incident and are working with suppliers to understand the root cause and whether it …
Responded
John Matthews
Concerns: Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Response (Stockport NHS Trust): The Trust has formally discussed neurological observation needs in sisters' meetings and safety huddles, shared within the ED Quality Newsletter to all ED staff. To avoid a reoccurrence the Trust …
Responded
Rita Paton
Concerns: There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.
Overdue
Vera Williams
Concerns: Emergency Department doctors and staff lack a digital system to support their work.
Overdue
Michael Brennan
Concerns: A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.
Response (University College Hospitals NHS Trust): UCLH will revise its bed management policy by the end of May 2017 to reflect twice-daily bed state updates from Westmoreland Street Hospital. It is also implementing an electronic coordination …
Responded
Daniel Maher
Concerns: Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.
Overdue
John Griffiths
Concerns: The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.
Response (UHSM): UHSM acknowledges concerns regarding checking for recent patient presentations in the emergency department. They state the ED system alerts clinicians to previous attendances and that the Electronic Patient Record System …
Overdue
Robert Brown
Concerns: Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Response (the Director General of Prisons): NHS England and NHS Improvement are leading a project with HMPPS to implement inter-operability between SystmOne and NOMIS to improve information sharing; Phase one is delayed until August 2020 due …
Responded
Lee Thrumble
Concerns: Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
Overdue
Felicity Clough
Concerns: Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.
Response (Secretary of State for Health and Social Care Minister for Crime and Polici): The Secretary of State for Health and Social Care reports that Yeovil District Hospital has implemented measures to ensure staff can access pre-hospital information, including converting information from other systems …
Overdue
Ketheeswaren Kunarathnam
Concerns: Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Response (Home Office): The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by …
Responded
Daniel Ludlam
Concerns: The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
Response (Department of Health and Social Care): The Department highlights NHS Digital's response and notes that protocols exist for 'Early Exit' from NHS Pathways triage, involving clinician takeover when needed, and mentions the Delivery plan for recovering …
Overdue
Derek Larkin
Concerns: Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.
Response (NHS Dorset ICB): The ICB notes that patient information is accessible via the Dorset Care Record (DCR) and that this gentleman has had a DCR since February 2018, which has been accessed by …
Response (Dorset Council): Dorset Council confirms that they ensure health is consulted on medication, its use, storage and any risks at assessment and review points. They also confirm written confirmation from Health in …
Responded
Stephen Cassidy
Concerns: Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Response (NHS England): NHS England acknowledges concerns about accessing Summary Care Records and allergy information but primarily describes existing requirements and procedures. They highlight national work to share learnings from PFD reports.
Response (NHS North Bristol NHS Trust): The trust is exploring non-smartcard-based access to NCRS, with access planned for all staff in Q1 2024. They are also commissioning EPMA (Electronic Prescribing and Medicines Administration) for deployment in …
Responded
Andrew Bowles
Concerns: A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): The two Trusts have agreed to allocate access to hospital records for bank staff who regularly work shifts within the Psychiatric Liaison Team to improve information sharing. Issues will be …
Responded
Paul Gander
Concerns: A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.
Overdue
Evie Davies
Concerns: A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): The Trust clarifies the function of Cafe 71 and its liaison with the Trust and outlines how GPs are informed of contact with the crisis line, noting that the referral …
Response (Cheshire and Merseyside Integrated Care Board): NHS Cheshire and Merseyside Integrated Care Board will work with CWP and GP colleagues to improve the timeliness and content of correspondence from the Crisis Line.
Response (Spider Project 1): Spider Project 1 disputes several points in the coroner's report, clarifying that the deceased never contacted Cafe 71 directly and that the referral from the Crisis Line gave no indication …
Response (Spider Project Cafe): The cafe has changed its referral forms to include consent for leaving voicemails and to gather more information about existing support for the individual being referred.
Responded
Liam McCarlie
Concerns: Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Response (EMAS and Northamptonshire ICB): Northamptonshire ICB and Northamptonshire Healthcare NHS Foundation Trust (NHFT) have put in place a 24/7 mental health crisis service, run by NHFT, to support the ambulance service with access to …
Responded
Sophie Wilson
Concerns: Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies for vulnerable individuals.
Response (North East Ambulance Service): The North East Ambulance Service acknowledges the concerns regarding ambulance crews not being aware of the 'familiar faces plan'. They are instructing dispatch teams to verbally notify staff of any …
Responded
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Response (NHS England): NHS England detailed several actions taken to address the coroner's concerns, including: implementing a 'Complex Call' process to ensure clinicians assist health advisors with medication/medical related triaging, and providing 'Hot …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the coroner's concerns regarding the NHS Pathways system and patient information sharing, noting that NHS England is responding to the specific concerns …
Overdue
Caroline and Bernard Cleall
Concerns: Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities to revise safety packages.
Response (London Borough of Croydon): The council disputes the coroner's concern that its staff could not access records, stating that the records were available, and a review of care arrangements was carried out with awareness …
Responded
John Charles Spencer
Concerns: Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Response (NHS England): NHS England highlights existing functionalities such as the National Care Records Service (NCRS) and the SystmOne out-of-hours system that enable access to patient's Summary Care Record (SCR). They also note …
Response (Holderness Health): Holderness Health confirms it migrated to TPP SystmOne with GP Connect enabled for interoperability, but the patient's surgery was 14 years ago and not considered a significant active problem.
Response (CQC): The CQC contacted the GP practice and Out of Hours provider to establish circumstances and intended actions. They state they ensure that they look closely at how providers deal with …
Response (Royal College of General Practitioners): The RCGP will highlight the case to their health informatics group to influence discussions with NHS England and will also highlight the concerns to The Professional Record Standards Body (PRSB).
Responded
Chloe Ellis
Concerns: Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.
Response (West Yorkshire Integrated Care Board): The ICB is working to implement the Better Ambulatory Record Sharing (BaRS) system, which would allow EDs to access NHS 111 Online assessment data, with a target date of March …
Responded
Kwabena Amoateng
Concerns: A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.
Overdue
Amy Pugh
Concerns: Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
Response (NHS England): NHS England acknowledges the concerns raised and explains its commitment to improving Electronic Patient Records (EPRs) across all NHS Trusts and supporting the sharing of critical clinical information across NHS …
Responded
Jean Groves
Concerns: Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Response (Norfolk County Council): Norfolk County Council plans to issue a communication to all operational managers and reablement liaison officers to remind them to record every referral (accepted or declined) and all attempts to …
Response (Careline365): Careline365 reviewed its internal procedures for recording and communicating property access information, confirming adherence to TEC Monitoring module standards and no operational failing on their part. They clarified that the …
Responded
Akhona Moyo
Concerns: Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.
Response (University Hospitals of Northamptonshire NHS Group): • The Northamptonshire Care Record (NCR) is now available at NGH, providing clinicians with access to GP data including medications, allergies, diagnoses, and lists of GP consultations. • GP Connect …
Response (Department of Health and Social Care): • The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue. • The Single …
Overdue
Committee Recommendations (13)
#20 —
Recommendation: NHS health and publicly funded social care services are legally required, by the Accessible Information Standard, published under section 250 of the Health and Social Care Act 2012, to provide health and care information to patients and service users in …
Gov response: It is really important that information that is meant to be for everyone is made accessible for everyone. This includes patients, people who use services, parents and carers with a disability. The NHS and some …
Under Consideration
#15 —
Recommendation: We heard that more needs to be done to improve the way a disabled person’s communication preferences are recorded by Jobcentre Plus. DWP should take inspiration from the Accessible Information Standard model used in the NHS and create an automated …
Gov response: Marketing campaign DWP is committed to improving awareness of Access to Work. We have delivered a paid communication campaign to increase awareness of Access to Work and increase take- up of grants. The proactive communication …
Under Consideration
#19 —
Recommendation: The accessibility of the Government’s communications to disabled people during the pandemic has been poor from the outset of lockdown in March. The Government has been far too slow to address concerns, notably about the lack of British Sign Language …
Gov response: We want information about Coronavirus to be accessible. We have provided important information about the Coronavirus in an accessible way. It has been good to work with disability organizations to help get important information to …
Under Consideration
#21 —
Recommendation: We agree with organisations representing Deaf British Sign Language users that we should set a good example in the accessibility of our public oral evidence sessions. It is regrettable that we did not provide live BSL interpretation and subtitles via …
Gov response: We agree with this. We hope the House of Commons comes up with a plan to have more British Sign Language.
Under Consideration
#14 —
Recommendation: It is unacceptable that some disabled people still face barriers when trying to access services through Jobcentre Plus. It is particularly shocking that services provided by the Department for Work and Pensions, whose ministerial team includes the Minister for Disabled …
Gov response: As planned, in October 2021 Government entered private live testing of an early version of a service to support employers managing health and disability in the workplace. This is designed to help prevent avoidable job …
Under Consideration
#11 —
Recommendation: Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.
Gov response: The government accepts this recommendation. The government recognises the importance of data sharing across relevant bodies. Existing legislation, such as the Civil Contingencies Act 2004, provides a framework for emergency preparedness and response, including duties …
Under Consideration
#16 —
Recommendation: The Department told us that the use of remote hearings is at the discretion of the judge in each individual case, and that everybody is entitled to have their reasonable adjustments considered by the judge. However, a third of people …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2024 5.2 As part of the evaluation of HM Courts & Tribunals Service (HMCTS) reform, HMCTS will consider the experience of criminal court …
Not Addressed
#15 —
Recommendation: Since the start of the pandemic, the Department and HMCTS have significantly increased the use of hearings held remotely using video technology, and plan to continue to use them to reduce the backlog in the courts.25 We asked what impact …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2024 5.2 As part of the evaluation of HM Courts & Tribunals Service (HMCTS) reform, HMCTS will consider the experience of criminal court …
Not Addressed
#5 —
Recommendation: Vulnerable users and people from ethnic minority backgrounds are potentially impacted disproportionately by efforts to tackle the Crown Court backlog, which the Department and HMCTS have not done enough to understand. Since the start of the pandemic, HMCTS significantly increased …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2024 5.2 As part of the evaluation of HM Courts & Tribunals Service (HMCTS) reform, HMCTS will consider the experience of criminal court users. …
Not Addressed
#16 —
Recommendation: Additionally, Mencap raised concerns with us about specific difficulties in identifying and prioritising people with severe and profound learning disabilities.38 It said there was a need for more accessible communications for this group and to tackle needle phobia, which had …
Gov response: 2: PAC conclusion: Comparatively low vaccination uptake persists in many vulnerable groups and, after the first booster campaign, has even dropped further for some. 2. PAC recommendation: Recognising that reasons for lower uptake will vary, …
Not Addressed
#10 —
Recommendation: The widespread adoption of continuous facemask wearing in health and social care settings has made effective communication impossible for patients and healthcare professionals who lip-read, and much more difficult for Deaf people who use British Sign Language and people with …
Gov response: We agree that extra money is needed to support children and young people who have special educational needs and a disability to catch up on learning. We have given extra money to provide education. But …
Under Consideration
#10 — Streamlined asylum questionnaires poorly designed, lack clear instructions, and are only available in English.
Recommendation: However the UNHCR, as well as the Public Law Project and Dr Jo Wilding from the Migration Law Clinic, have raised concerns about the streamlined asylum process questionnaire.23 Though the Home Office told us that it had worked with the …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 The Home Office has written to the Committee (9 January 2024) in a supporting letter addressing the bullets in this recommendation.
Accepted
#3 — Require Ofcom to use internet access data for assessing linear content accessibility.
Recommendation: Allowing Public Service Broadcasters to use a wider range of services to contribute towards their remit, including on-demand, should not come at the expense of linear broadcast audiences. It is imperative that broadcasters make their content as accessible as possible …
Response Pending
CQC Inspection Actions (2)
Meet The Baby
The provider must ensure that there is access to independent interpreters to assist women whose first language is not English or who may have a hearing impairment to ensure that a relative does not act as an interpreter where there …
Must Do
DMC Church View Practice
Review do not attempt cardiopulmonary resuscitation (DNACPR) forms to ensure they are accessible to all.
Should Do
IOPC Learning Recommendations (3)
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) review relevant policies and/or procedures to ensure they make clear the need to set up a password with nursing staff when officers have transported a medical emergency to hospital. A password …
Recommendation - Hampshire Constabulary, September 2024
The IOPC recommends that Hampshire Constabulary creates and implements a memorandum of understanding (MOU) regarding sharing patient information with University Hospital Southampton NHS Foundation Trust. This follows an investigation in which a man was found by police in a hospital …
Recommendation - Metropolitan Police Service, February 2023
The IOPC recommends that the Metropolitan Police Service (MPS) explores the options, to include making an audio-recording, to ensure the Police and Criminal Evidence Act 1984 Codes of Practice are accessible in custody for detained persons with sight impairment. Any …
IMB Recommendations (45)
Springhill (2022)
Ensure the delivery of health champions and the wellbeing hub, as well as improved access to healthcare data.
Governor / Director
Gartree (2023)
The following question is repeated from last year’s annual report: will the Prison Service work with the Board to ensure that it has access to necessary information, such as healthcare data, for example, so that the Board is able to monitor more effectively how well the prison is meeting the standards and requirements placed on it and what impact these …
HMPPS
Gartree (2023)
The Board has continued to struggle to obtain meaningful data about healthcare provision to enable monitoring of waiting lists and patients’ clinics, etc, so that we can ascertain whether or not they are being provided at a satisfactory level.
Ministry of Justice
Bedford (2023)
The lack of a suitable computer in the healthcare rooms in reception means that healthcare staff cannot access the personal escort records.
Governor / Director
London STHF (2024)
Delays and unavailability of certain languages in The Big Word translation service need to be addressed.
Other
Gatwick IRC (2024)
Ensure that suitable training and support is provided so that professional interpretation services are used effectively in communications with the detained men, particularly during critical safeguards such as initial screening, and Rule 34 and 35 appointments.
NHS / Healthcare Provider
North East Midlands, Yorkshire & Humber STHF (2025)
In the light of delays in ambulance and paramedic attendance following an incident at Swinderby RSTHF, we recommend the use of ‘what3words’ or other precision location tools to aid navigation to places of detention and that lists of such places with the location details be readily available to paramedic crews. This is relevant not just for places such as Swinderby …
NHS / Healthcare Provider
Highpoint (2020)
In order for mental health practitioners to provide timely interventions, there is a requirement for prisoner records to be transferred between establishments when a prisoner is relocated. The Board asks for a co-ordinated and regulated procedure to be established to ensure this happens.
HMPPS
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Home Office should arrange for Wi-Fi and internet access for detainees, even if it is only available when DCOs can supervise (para. 8.12 – 8.13; 12.13 – 12.15; 25.4; 33.4).
Home Office
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Home Office should speed up their introduction of electronic translation devices, which they have already trialled (para. 4.11; 8.4; 17.3).
Home Office
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Board repeats the request for dual handset phones so that Detainee Custody Officers (DCOs) and detainees can use the Big Word interpretation service more easily and with privacy (para. 4.10; 17.2).
Home Office
Oakwood (2022)
During the reporting year the Board has been concerned that the healthcare complaint boxes were not emptied on a regular basis and their location is not easily accessible to all prisoners at all times. The Board asks the Director to review this with the head of healthcare (see para 6.1).
Governor / Director
Gatwick IRC/RSTHF (2022)
Review the service offered by Big Word and consider alternatives where they will improve availability (section 5.5).
Home Office
Gatwick IRC/RSTHF (2022)
Strengthen the consideration given by caseowners to local knowledge (Home Office, Serco and PPG) about a detained man’s situation and condition, especially through the AAR mechanism, and review the thresholds applied to the balance between immigration factors and humanitarian considerations (section 4.4).
Home Office
Erlestoke (2022)
What is the solution to improve the IT infrastructure so medical records can be accessed across the estate to ensure prisoners are not put at risk?
NHS / Healthcare Provider
Bedford (2022)
The digitising of the personal escort records has made it harder for healthcare staff to access them.
HMPPS
Erlestoke (2023)
What is the solution to improve the IT infrastructure so medical records can be accessed by healthcare staff across the estate to ensure prisoners are not put at risk?
Governor / Director
Dartmoor (2023)
What more can be done to ensure that Foreign National Prisoners, some of whom have little or no English, have access to notices and information provided in their own language(s)?
Governor / Director
Isle of Wight (2024)
Can appropriate equipment/instruction materials be immediately installed in the IHU so that translation services are available for prisoners located there and for prisoners who arrive outside of core hours when initial health screening takes place in the unit?
Governor / Director
Gatwick IRC (2024)
Establish suitable mechanisms with relevant other parties to ensure that information regarding men's medical conditions/medication, vulnerabilities or security risks arrives with them or is shared in a timely way.
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB would like to have reassurance that centre protocols are to be revised to ensure that explicit procedures are in place to enable healthcare professionals (both internal staff and external paramedics) to attend health emergency incidents as quickly as possible – including the allocation of fast escort staff to facilitate this and the use of locational tools such as …
Other
Portland (2020)
The number of prisoners failing to attend for pre-arranged healthcare appointments because operational support grade (OSG) staff have not followed agreed protocols is not acceptable. This is the second year running that this situation has ensued.
Governor / Director
Foston Hall (2020)
The lack of suitable interview rooms across the prison, to facilitate welfare and rehabilitative work with prisoners (see paragraphs 5.5.6, 6.1.10 and 7.5.2).
Governor / Director
Foston Hall (2020)
There is a lack of suitable interview rooms across the prison, for use by healthcare staff, psychologists, chaplains and other service providers, which significantly undermines the delivery of positive rehabilitative work (see paragraphs 5.5.6, 6.1.10 and 7.5.2).
HMPPS
Erlestoke (2020)
Communication between Prison Reception Staff and Healthcare Reception Staff is unsatisfactory (see paragraph 8.7). Will this problem be addressed?
Governor / Director
Parc (2021)
There were issues surrounding the ability of healthcare staff to provide an appropriate service to prisoners as a consequence of there being insufficient telephones available. Any issue of this nature should be treated as an absolute priority.
Governor / Director
Huntercombe (2021)
To develop a process with healthcare to ensure there is documented sharing of appropriate health information with prison staff (paragraph 6.1.8.).
Governor / Director
Erlestoke (2021)
Will further efforts be made to ensure that firstly, prison staff liaise with healthcare staff to inform them of forthcoming reviews and secondly that better arrangements are made to schedule reviews for healthcare operating hours?
Governor / Director
Oakwood (2022)
A further concern for the Board is the fact that the letter sent to explain how a request will be dealt with is long and not always clear for prisoners who cannot read easily or whose first language is not English. These multi-functional response letters are not dated and do not have any reference numbers assigned for easy identification in …
Governor / Director
London Heathrow and City Airports (2022)
[All holding rooms] The Board recommends that Wi-Fi is accessible in the holding rooms for those with hearing and speech impairment, so that they can communicate with DCOs. (See paragraphs 4.3.35 – 4.3.37)
Home Office
Thameside (2023)
Please can those in HMPPS with responsibility for contracted out prisons ensure that all IMBs in those prisons have access to the same resources as our colleagues in the public sector, as there is much discrepancy and full access to NOMIS has been an issue for a number of years and is still not fully resolved.
HMPPS
Kent Coast Short Term Holding Facilities (STHF) (2023)
Have visual information on the screens and for interviewing instead of just written format.
Home Office
London STHF (2024)
We repeat the recommendation that the detention contractor should ensure that DCOs use The Big Word interpretation service for inducting non-English-speaking passengers and that they should not assume that passengers with a limited grasp of English really understand what they are being told.
Other
Kent Coast Short Term Holding Facilities (STHF) (2024)
The Board recommends that there should be visual information on the screens instead of it just being in a written format. In addition, detained people should have access to visual aids to help them when they are being interviewed.
Home Office
Berwyn (2024)
The Board recommends putting in place measures to radically improve the take up of internal medical appointments.
Governor / Director
Five Wells (2025)
What steps are being taken to introduce electronic communication between the healthcare unit and prisoners?
Governor / Director
Five Wells (2025)
What steps are being taken to introduce electronic communication between the healthcare unit and prisoners?
Governor / Director
Chelmsford (2025)
Launchpad has been a great success in allowing prisoners to check and verify personal information. Will the Prison Service commit to adding a feature so prisoners can book and manage their medical appointments? If so, what timeline do you anticipate for implementation?
HMPPS
Gatwick, Stansted, Luton and Lunar House (2020)
We do not believe that the arrangements for the monitoring of the medical welfare of detained individuals within the holding rooms are adequate and in particular there is potential risk to the health of an individual who needs urgent access to their medication or medical equipment.
Home Office
Swaleside (2021)
The continued occupancy of the life limited room in Healthcare by one paraplegic resident whose needs are different, whilst there are a number of other residents who qualify for the use of this room. (see sections 3.1 and 6.1)
HMPPS
Stafford (2021)
Will HMPPS provide direction to the population management unit (PMU) that they must take more responsibility regarding the suitability of residents they transfer to HMP Stafford (e.g. residents who cannot manage stairs yet the sending prison has categorised them as fit and well)? Inappropriate transfer of the kind seen during the period of this report places unfair pressure on prison …
HMPPS
Isle of Wight (2023)
How will the Governor ensure translated induction material is always available and remove possible barriers to the use of translation services. This should include providing speaker telephones and training for health workers who cover reception health screening outside of core hours from the IHU.
Governor / Director
Bedford (2024)
We are concerned about the large rise in applications we have received about healthcare, the general negative view of prisoners and the lack of access to healthcare managers.
Governor / Director
London short term holding facilities (STHF) (2025)
The Board would like the lack of signal in Terminal 2 to be urgently addressed, so that a translation device can be used to communicate with detained people.
Ministry of Justice
Belmarsh (2025)
Will the Prison Service look at ways of providing a technological solution, such as computer tablets, to assist in translations for foreign national prisoners with limited English, particularly in a healthcare setting?
HMPPS
PHSO Casework Decisions (12)
P-004381 — Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board
Ms P complains about the BSL interpreting service provided by the ICB. She complains the ICB failed to commission an interpreting service that meets her needs as a deafblind person.
NHS in England
Dec 2025
P-001862 — Health Assessment Advisory Service
Mr U complains the organisation refused his request for a home-based or paper-based assessment instead of a face-to-face one. He complains it failed to account for the supporting evidence from his GP about his medical conditions, as well as the events of his previous attendance at the assessment centre in …
UK Government
Mar 2023
P-002035 — Barts Health NHS Trust
Miss W complains on behalf of her sister, Miss X. She complains that when Miss X went for brain surgery there was no plan and the Trust had not arranged for a British Sign Language interpreter. She says this made communication difficult and the Trust did not consider Miss X's …
NHS in England
Jun 2023
P-003043 — Birmingham Community Healthcare NHS Foundation Trust
Mrs E complains that since 2018 the Trust has held multi-disciplinary team meetings and discussions about the care of her son without her. She also complains that since 2020, the Trust has made decisions about his epilepsy treatment without seeing him.
NHS in England
Oct 2024
P-003798 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complains about her father's care in 2021. She says the Trust did not listen to their concerns or arrange regular BSL interpreters to help with his needs.
NHS in England
Partly Upheld
Mar 2025
P-003810 — An independent provider in the Gloucester area
Mr E complains about the Practice's failure to make reasonable adjustments and about the ICB's handling of his complaint.
NHS in England
Aug 2025
P-004462 — A practice in the Lincoln area
Mr H said a Practice in the Lincoln area failed to provide him with reasonable adjustments when booking appointments between October 2024 and April 2025.
NHS in England
Upheld
Nov 2025
P-001745 — Royal Berkshire NHS Foundation Trust
Mrs U says the Trust did not provide reasonable adjustments to support her autistic daughter to attend hospital. Mrs U says this delayed investigations and treatment.
NHS in England
Jan 2023
P-002796 — Hull University Teaching Hospitals NHS Trust
Mr R complains that when his mother was in hospital in June 2022 the Trust ignored his status as Lasting Power of Attorney and did not communicate with him. He also complains it did not put a deprivation of liberty safeguard (DoLS) in place for his mother and discharged her …
NHS in England
Jul 2024
P-003038 — Mid and South Essex NHS Foundation Trust
Miss U complains Mid and South Essex NHS Foundation Trust did not appropriately assess her symptoms during visits to its emergency department on 20 January and 5 April 2023. She also complains it refused to call her multiple sclerosis nurse during the same visits.
NHS in England
Oct 2024
P-002413 — North West Anglia NHS Foundation Trust
Miss I complains that a nurse was unprofessional during a medication appointment and did not recognise her communication needs. She also complains the Trust does not make reasonable adjustments for deaf people when sending out information and it did not follow the complaints procedure.
NHS in England
Jan 2024
P-002368 — NHS England
Mr E complains that NHS England’s Special Care Dental Service Guidance does not take into account the Equality Act and the policy makes it difficult for autistic people to access good dental care.
NHS in England
Dec 2023
LGO / SPSO Decisions (65)
21-003-521 — Sefton Metropolitan Borough Council
Summary: Mr X complained about the Council’s decision not to provide him with a Blue Badge. He says the Council did not properly consider his application and this caused him avoidable distress and inconvenience. We found fault regarding the Council’s communications with Mr X. The Council has agreed to reconsider …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-004-654 — Royal Borough of Greenwich
Summary: The Council was at fault for the way it dealt with Mr X’s housing application. The Council delayed in referring Mr X to an Occupational Therapist, delayed in reviewing Mr X’s medical priority and request for an additional bedroom and was at fault for the way it reached its …
LGO (Local Government & …
Housing
Upheld
Feb 2022
21-006-708 — Nottinghamshire County Council
Summary: Mr B was unable to make an online application for a Blue Badge because of his disability. There was fault in the Council’s failure to offer an alternative way to apply for Mr B. The Council has already remedied this fault as it offered a telephone application to Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-223 — London Borough of Croydon
Summary: The Council failed to properly consider Mrs X’s application for a blue badge because it failed to record the reasoning for its decisions and failed to undertake a mobility assessment.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
23-014-778a — Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in …
LGO (Local Government & …
Health
Upheld
Sep 2024
NIPSO-202002242 — Education Authority
NIPSO (NI Public Service…
Education
Nov 2022
21-006-479 — London Borough of Southwark
Summary: Mr R complained about the way the Council dealt with his application to its housing. The Council made him a direct offer of unsuitable accommodation. And it did not consider medical evidence he submitted. The Ombudsman upholds the complaint about a delay in considering Mr R’s medical evidence. But …
LGO (Local Government & …
Housing
Upheld
Jul 2022
23-011-152a — Calderdale & Huddersfield NHS Foundation Trust (23 011 …
Summary: Ms D complains about faults by Calderdale Metropolitan Borough Council and Calderdale & Huddersfield NHS Foundation Trust in managing her mother, Mrs X’s, discharge from hospital. We have upheld Ms D’s complaints about assessing Mrs X’s ability to make her own decisions, consent and sharing information about community nursing …
LGO (Local Government & …
Health
Upheld
Aug 2024
23-018-381 — London Borough of Lewisham
Summary: Ms Q complained about the Council’s handling of her housing application and assessment of medical priority. She said she experienced distress due to the impact her housing circumstances had on her. We found the Council at fault for causing significant delays in her 2022 request for medical priority, but …
LGO (Local Government & …
Housing
Upheld
Aug 2024
23-019-136 — London Borough of Lewisham
Summary: Miss B complained about the way the Council considered her medical needs in connection with her housing application. We have found some fault in the way the Council communicated its decisions to Miss B. But we consider the Council’s most recent review properly explained the decision. The Council has …
LGO (Local Government & …
Housing
Upheld
Aug 2024
25-007-329 — Cambridge City Council
Summary: We will not investigate this complaint about the Council’s management of Mr X’s council tax account nor its failure to make its telephone line more accessible for disabled users. This is because an investigation would not lead to a different outcome for Mr X.
LGO (Local Government & …
Benefits And Tax
Oct 2025
25-009-696 — London Borough of Waltham Forest
Summary: We will not investigate this complaint about the Council’s failure to consider medical evidence when assessing the suitability of Miss X’s temporary accommodation. This is because the Council has agreed to a suitable remedy.
LGO (Local Government & …
Housing
Upheld
Dec 2025
25-004-529 — Westminster City Council
Summary: We will not investigate this complaint about the Council’s failure to consider Mr X’s medical conditions when he applied for a change in banding on medical grounds. This is because the matters complained about are currently being raised in court.
LGO (Local Government & …
Housing
Dec 2025
21-005-008 — Kent County Council
Mr C complained the Council failed to consider all his medical information before refusing his Blue Badge application.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-007-457 — Kent County Council
Summary: Mr X complained about the Council’s refusal to issue a blue parking badge to him. He said that, as a result, it is more difficult for him to access the community and he undertakes fewer journeys. We found there was no fault with regards to the Council’s actions.
LGO (Local Government & …
Adult Care Services
Not Upheld
Feb 2022
21-015-284 — London Borough of Richmond upon Thames
Summary: We will not investigate this complaint about equipment a council occupational therapist placed in the complainant’s parents’ home. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. It is not unreasonable to expect the complainant to …
LGO (Local Government & …
Adult Care Services
Feb 2022
21-010-362 — Cornwall Council
Summary: Mr B complains the Council has not properly assessed his eligibility for a Blue Badge. The Council considered the evidence Mr B provided but it told Mr B that he could not provide information from his GP and this was fault. The Council has agreed to apologise to Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-001-564 — London Borough of Haringey
Summary: Ms B complained about the delay in dealing with her complaint about children’s services. We found the Council delayed in completing the process and has not yet sent Ms B the reports in an accessible format. We have asked the Council to pay her £150 and send her the …
LGO (Local Government & …
Children S Care Services
Upheld
May 2022
21-014-849 — North Northamptonshire Council
Summary: The Council is not at fault for not allowing Miss X to bid on non adapted properties. It is at fault for removing Miss X’s priority for a level access shower when she asked for a bath with bath chair to be included with her housing application and for …
LGO (Local Government & …
Housing
Upheld
May 2022
22-002-137a — Manchester University NHS Foundation Trust (22 002 137a)
Summary: The Ombudsmen cannot investigate Mrs P’s complaint about a meeting to review her son L’s Education Health and Care Plan. This is because we cannot investigate complaints about what happens in schools and any actions of the Council that are inseparable from these events. We have decided not to …
LGO (Local Government & …
Health
Sep 2022
22-002-137 — Manchester City Council
Summary: The Ombudsmen cannot investigate Mrs P’s complaint about a meeting to review her son L’s Education Health and Care Plan. This is because we cannot investigate complaints about what happens in schools and any actions of the Council that are inseparable from these events. We have decided not to …
LGO (Local Government & …
Education
Sep 2022
22-000-794 — London Borough of Lambeth
Summary: There was fault in the Council’s actions. The Council has not carried out a mental capacity assessment of Mr C and has not considered alternative accommodation for him in his care plan. There were delays in the provision of suitable transport for Mr C to go to college. The …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-018-660 — Kent County Council
Summary: We will not investigate this complaint about the Council’s decision not to issue a Blue Badge to a group that provides transport for disabled people. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-020-919 — London Borough of Newham
Summary: We will not investigate this complaint about the Council failing to address Mr X’s need for a virtual court hearing due to his disability. The Council has upheld Mr X’s complaint and withdrawn the court action. We could not add anything more by investigating.
LGO (Local Government & …
Benefits And Tax
Upheld
May 2024
24-001-044 — Devon County Council
Summary: We will not investigate this complaint about an unsuccessful application for a Blue Badge. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
May 2024
23-020-881a — Gloucestershire Health and Care NHS Foundation Trust (23 …
Summary: We will not investigate a complaint about how a Trust and a Council dealt with a complaint about the care provided to the complainant’s brother. This is because he did not provide consent to share his information and this was appropriately considered by the organisations during the local complaints …
LGO (Local Government & …
Health
Jul 2024
23-020-881 — Gloucestershire County Council
Summary: We will not investigate a complaint about how a Trust and a Council dealt with a complaint about the care provided to the complainant’s brother. This is because he did not provide consent to share his information and this was appropriately considered by the organisations during the local complaints …
LGO (Local Government & …
Adult Care Services
Jul 2024
24-013-580 — London Borough of Lewisham
Summary: Mrs Y complains on behalf of her husband, Mr Y, that he has not been awarded a blue badge. Mrs Y says the Council failed to fully consider the evidence before making its decision. Mrs Y says this has caused stress and frustration and has isolated and affected Mr …
LGO (Local Government & …
Adult Care Services
Not Upheld
Apr 2025
24-017-995 — Folkestone & Hythe District Council
Summary: We will not investigate this complaint about the Council’s assessment of the complainant’s priority for housing which allegedly failed to consider her households medical needs. This is because the Council’s housing decision carried a right of review and it would be reasonable for her to have requested this and …
LGO (Local Government & …
Housing
Apr 2025
24-014-125 — London Borough of Tower Hamlets
Summary: Mr X complains the Council failed to properly consider the problems that arose in his assessment when he appealed its decision to refuse him a blue badge. We find fault with the Council’s response to his appeal and have agreed another assessment considering Mr X’s reasonable adjustments.
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2025
25-004-558 — London Borough of Hounslow
Summary: We will not investigate this complaint about an unsuccessful application for a blue badge. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Aug 2025
24-020-635 — Worcestershire County Council
Summary: Mrs B complained on behalf of her father, Mr C that the Council had failed to make reasonable adjustments to ensure Mr C could read and understand financial information about his care costs, despite knowing he had a visual impairment. We found fault in the Council’s actions which meant …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
25-006-475 — Cambridgeshire County Council
Summary: We will not investigate Mr X’s complaint about the Council’s decision to refuse him a Blue Badge. There is insufficient evidence of fault to warrant an investigation.
LGO (Local Government & …
Adult Care Services
Oct 2025
24-006-067 — London Borough of Newham
Summary: Ms C complains the Council has failed to renew her Blue Badge application. The Council is at fault for delay, and failing to provide proper reasons for rejecting Ms C’s review. This has caused Ms C uncertainty about whether the Council has properly considered her review request and her …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
201804596 — Edinburgh Health and Social Care Partnership
C complained to us about two matters relating to the partnership. Firstly, they were concerned about an occupational therapy assessment carried out to identify appropriate adaptations for a new property they were being offered, as they did not consider the adaptations made met their needs as a disabled person. Secondly, …
SPSO (Scottish Public Se…
Health and Social Care
Not Upheld
May 2021
25-000-692 — London Borough of Tower Hamlets
LGO (Local Government & …
Adult Care Services
21-012-075 — London Borough of Islington
Summary: We will not investigate this complaint about the complainant’s application for a Blue Badge and a taxi card. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Jan 2022
21-014-850 — London Borough of Ealing
Summary: We will not investigate this complaint about the Council’s decision not to award a Blue Badge. This is because the Council has offered to do a further assessment and it is unlikely we could add to the Council’s response.
LGO (Local Government & …
Adult Care Services
Feb 2022
22-000-060 — London Borough of Merton
Summary: We will not investigate this complaint about the Council’s decision not to award a blue badge for Mr X. There is not enough evidence of fault in the way the Council made its decision.
LGO (Local Government & …
Adult Care Services
May 2022
21-012-236 — Royal Borough of Greenwich
Summary: Mr X complained the Council decided not to replace the through lift in his property with a stairlift or sit-down lift. Mr X says the through-lift in place is not fit for purpose and is causing him distress and worry. The Ombudsman does not find fault with how the …
LGO (Local Government & …
Adult Care Services
Not Upheld
May 2022
21-011-626 — Gravesham Borough Council
Summary: The Council is at fault for failing to consider medical evidence Miss X provided in support of her housing application. The Council is also at fault for failing to consider any reasonable adjustments it could have made when corresponding with Miss X. We find this caused her distress and …
LGO (Local Government & …
Housing
Upheld
Aug 2022
23-018-219 — London Borough of Islington
Summary: We will not investigate this complaint about the Council’s decision to refuse a blue badge. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Adult Care Services
Mar 2024
23-013-485 — London Borough of Tower Hamlets
Summary: Mr X complained the Council refused to accept appropriate alternative documentation confirming the lease arrangements for his vehicle and declined his application for a residents parking permit. There is no evidence of fault in the way the Council considered Mr X’s application to transfer his parking permit.
LGO (Local Government & …
Transport And Highways
Not Upheld
Apr 2024
23-017-514 — London Borough of Tower Hamlets
Summary: There is no evidence the Council failed to take all relevant information into account when it decided not to award a Blue Badge.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2024
24-001-312 — London Borough of Newham
Summary: Miss X complained the Council failed to rehouse her to a larger property on medical grounds and failed to properly respond to her complaint. The Council was not at fault when it decided Miss X did not have a medical need for an extra bedroom. It accepted it was …
LGO (Local Government & …
Housing
Upheld
Oct 2024
24-008-433 — Essex County Council
Summary: We will not investigate Ms X’s complaint about the Council’s handling of her blue badge application. She says the Council delayed in processing her application. This is because the potential fault has not caused significant injustice.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-001-089 — Peterborough City Council
Summary: There was no fault in how the Council considered Mr B’s blue badge application. Although it disregarded some evidence, it has fully explained why it did so. In the absence of any fault in the Council’s decision-making, we have no power to question the decision itself.
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2024
24-023-017 — London Borough of Bromley
Summary: We will not investigate this complaint about how the Council dealt with an application for a Blue Badge. This is because there is insufficient evidence of fault.
LGO (Local Government & …
Adult Care Services
May 2025
24-020-966 — Rochdale Metropolitan Borough Council
Summary: We will not investigate Mrs X’s complaint about the Council’s decision to refuse her son Mr Y’s Blue Badge application and appeal, its consideration of his medical evidence, the basis of its decision-making, or the time the Council took to issue its decisions. There is not enough evidence of …
LGO (Local Government & …
Adult Care Services
May 2025
25-000-283 — East Sussex County Council
Summary: We will not investigate this complaint about the Council’s decision to refuse a Blue Badge because there is not enough evidence of fault.
LGO (Local Government & …
Adult Care Services
Jun 2025