Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
1,708 items
16 sources
10 inquiries
Source spread
Where this theme appears
Inaccurate and inaccessible patient records has been flagged across 16 independent accountability sources:
30 inquiry recs
648 PFD reports
22 committee recs
173 CQC actions
4 HMICFRS recs
2 ICIBI recs
89 PPO recs
6 IOPC recs
10 NAO recs
9 IMB reports
25 IMB recs
2 patient safety alerts
18 Article 2 learning points
2 detention investigation recs
204 PHSO decisions
464 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 (30)
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in …
Gov response: No formal response published by this government.
Unknown
R38 — Medical record keeping
Recommendation: Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Gov response: Section 4.2 of the Scottish Government's response directly addresses recommendation 38, which relates to clear, accurate, and legible patient records kept by doctors, emphasizing their integral role in good patient care. The General Medical Council …
Accepted
R20 — Stool records for CDI patients
Recommendation: Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
Gov response: Section 4.2 of the Scottish Government's response outlines the professional standards for record-keeping for nurses. The revised NMC code requires nurses and midwives to complete all records accurately and without any falsification, and to identify …
Accepted
R19 — ICN instructions recorded
Recommendation: Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Gov response: Section 4.2 of the Scottish Government's response details the professional standards for record-keeping for nurses and doctors. The revised NMC code requires nurses and midwives to complete all records at the time or as soon …
Accepted
R15 — CDI patient observations records
Recommendation: Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Gov response: Section 4.2 of the Scottish Government's response outlines professional standards for record-keeping. The revised NMC code, which all nurses and midwives must follow, specifically requires them to complete all records accurately and without any falsification, …
Accepted
R14 — Patient records compliance audit
Recommendation: Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Gov response: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear, accurate, and contemporaneous records. While the text does not explicitly state …
Accepted
F244 — Common information practices shared data and electronic records
Recommendation: There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
IBI-4d — Patient Records Audit
Recommendation: Patient Records: Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels …
Gov response: NHS England's Frontline Digitisation programme aims for all secondary care trusts to have electronic patient record systems. Plans exist to publicly report findings by summer 2025. Scotland will expand Digital Maturity Assessments by 2025 for …
Accepted
No update 2+ yrs
BRIS-18 — Provide parents of young children with copies of all inter-professional healthcare letters
Recommendation: Parents of those too young to take decisions for themselves should receive a copy of any letter written by one healthcare professional to another about their child’s treatment or care.
Unknown
BRIS-17 — Ensure patients receive copies of all inter-professional letters about their care
Recommendation: Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Unknown
R30 — Fluid balance monitoring
Recommendation: Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts as accurately as possible.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
Accepted
R27 — Positional change records
Recommendation: Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
Accepted
R26 — Wound documentation
Recommendation: Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code requires nurses to maintain clear and accurate records, completing them as soon as possible after an event …
Accepted
R24 — TVN instructions recorded
Recommendation: Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, requires clear and accurate records to be maintained, completed at the time of …
Accepted
R22 — Relative discussions recorded
Recommendation: Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, effective from March 2015, requires nurses and midwives to complete clear and accurate records at the time …
Accepted
IHRD-24 — Blood Test Result Documentation
Recommendation: All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Gov response: Blood test documentation standards updated. Serum sodium recording on fluid balance charts implemented.
Accepted
38 — Improve perinatal mortality recording
Recommendation: Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
SP50 — Healthcare trust risk information visibility
Recommendation: The Department of Health and Social Care / NHS England should ensure that all healthcare trusts involved in the care of children and young people who are at risk of acts of violence against others have systems that ensure that: …
Response Pending
LAMI-12 — Require front-line staff to record basic child information at first contact
Recommendation: Front-line staff in each of the agencies which regularly come into contact with families with children must ensure that in each new contact, basic information about the child is recorded. This must include the child’s name, address, age, the name …
Unknown
BRIS-9 — Develop kitemarking system for reliable internet health information guidance for public
Recommendation: The public should receive guidance on those sources of information about health and healthcare on the Internet which are reliable and of good quality: a kitemarking system should be developed.
Unknown
BRIS-8 — NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Recommendation: The NHS Modernisation Agency should make the improvement of the quality of information for patients a priority. In relation to the content and the dissemination of information for patients, the Agency should identify and promote good practice throughout the NHS. …
Unknown
BRIS-7 — Regularly update and pilot patient information materials with active patient involvement
Recommendation: Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.
Unknown
BRIS-6 — Provide evidence-based patient information in a comprehensible summary format
Recommendation: Information should be based on the current available evidence and include a summary of the evidence and data, in a form which is comprehensible to patients.
Unknown
R39 — DNAR decision awareness
Recommendation: Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
Gov response: Section 4.1 of the Scottish Government's response notes that recommendation 39 focuses on the clinically and ethically challenging aspects of Do Not Attempt Cardiopulmonary Resuscitation (DNAR) orders. The report sets out precise standards for decision-making, …
Accepted
R18 — Care planning system
Recommendation: Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
Gov response: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear and accurate records. This includes identifying any risks or problems and …
Accepted
IHRD-26 — Recording Clinical Discussions
Recommendation: Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.
Gov response: Documentation standards updated to require recording of clinical discussions and handovers.
Accepted
AS-9 — Medical Fitness for Detention Forms
Recommendation: Appropriate forms should be made available to allow a medical examiner to declare a detainee unfit for detention and questioning. The decision as to whether a detainee has been declared unfit for detention and questioning should be readily apparent and …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-5 — Detainee Capture and Condition Records
Recommendation: Appropriate procedures should be introduced to ensure that there is an accurate and detailed contemporaneous record of the circumstances relating to the original capture/detention of a prisoner and his general physical condition (including an appropriate photographic record) on arrival at …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
R29 — Patient weighing equipment
Recommendation: Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission and at least weekly thereafter.
Gov response: Section 3.1 of the Scottish Government's response addresses the need for appropriate equipment by detailing investment in NHS estates, assets, facilities, and equipment. The government has committed over £400 million to improve NHS infrastructure between …
Accepted
R10 — CDI patient information
Recommendation: Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.
Gov response: Section 4.2 of the Scottish Government's response highlights initiatives promoting person-centred care, including the 'Must Do with Me' elements, which emphasize 'what information do you need?' and patient involvement in decisions. The response also details …
Accepted
PFD Reports (648) — showing 50 strongest matches
Nicola Matthews
Concerns: Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
Overdue
Peter Pattinson
Concerns: Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Response (European Care Group): The care group has implemented new bed rail risk assessment and checking systems, along with staff training on safe bed rail usage. They also numbered daily statement documents to prevent …
Responded
Felix Cembrowicz
Concerns: The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Response (Avon and Wiltshire NHS Trust): Avon and Wiltshire NHS Trust will establish if re-referred patients have historic relapse management plans and an additional check should be undertaken in the RiO clinical records/documents to establish if …
Responded
John Lansdowne
Concerns: Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.
Overdue
Susan Jill Hammond
Concerns: Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.
Response (United Lincolnshire Hospitals NHS): United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between …
Responded
John Morgan
Concerns: Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" system pose risks to patient care.
Response (Welsh Government): The Welsh Government requested that Health Boards and Trusts review the incident and make changes as appropriate. The Chief Medical Officer and Chief Nursing Officer will write to all Health …
Overdue
Winston Llewellyn Johns
Concerns: Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Overdue
John William Wright
Concerns: A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.
Overdue
William Joseph Wilkinson
Concerns: Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.
Overdue
Stuart Aaron Collins
Concerns: Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Response (South Tees Hospitals NHS Foundation Trust): The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and …
Overdue
Keith Fleming
Concerns: The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
Overdue
Chloe Grace Flavell
Concerns: The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Overdue
Daniel Williams
Concerns: Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Response: The Trust has implemented a patient record development programme which provides alerts to staff, states a patient centred approach, and has rolled out training for staff and improved patient handovers. …
Responded
James Withers
Concerns: Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.
Overdue
Andrew John Fallon
Concerns: Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Overdue
Grace Mary Bates
Concerns: The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Response: A business case for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week …
Response: The Secretary of State for Health acknowledges the coroner's concerns regarding diabetes management at Barnet Hospital and refers to existing NICE quality standards and NHS England initiatives for improving patient …
Responded
Zeeyad Hamadi
Concerns: Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Response (Department of Health): The Secretary of State acknowledges the concerns and states that the National Offender Management Service (NOMS), NHS England and Public Health England (PHE) are due to meet to discuss governance …
Overdue
Christine Nutbeam
Concerns: Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent vomiting, contributing to surgical risks.
Overdue
John Malone
Concerns: A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Overdue
Desrae Tucker
Concerns: Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
Overdue
Bertha Cray
Concerns: Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Response (Barts Health NHS Trust): The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been …
Responded
Matthew Dunham
Concerns: Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Overdue
Frederick Davidson
Concerns: Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
Overdue
Caroline Lee
Concerns: Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
Overdue
Jack William Partington
Concerns: Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national policies for managing paralysing agents or neonatal ventilation.
Response (Department of Health): The Department of Health believes the issues are local and should be addressed by the Trust, noting existing guidance and the role of NHS England, but will notify the British …
Overdue
Kirk Duboise
Concerns: There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Response (Care UK): Care UK has implemented protocols for summoning ambulances, disseminated to staff via a Governor's notice and staff briefings. NOMS has implemented ACCT training, with further training for healthcare staff commencing …
Overdue
Michael James Meyler
Concerns: Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.
Response (HM Prison and Probation Service): HMP Manchester reception staff now record ROSH document existence and consideration of ACCT in NOMIS. Healthcare staff scan paper documents onto SystmOne. Weekly assurance checks of NOMIS entries are conducted …
Overdue
Yuki Ivy Norman-Knight
Concerns: Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.
Response (St Stephens Gate): St Stephens Gate has reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. They are arranging laminated copies of the NICE Traffic …
Responded
Nellie Travis
Concerns: The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
Overdue
Afifa Qaisar
Concerns: Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Overdue
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Response (HM Prison and Probation Service): Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is …
Overdue
Charles Bradley
Concerns: Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Overdue
David Chatburn
Concerns: The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Response (Department of Health): The Department of Health acknowledges the concerns raised regarding the patient's care and referral process, and notes that patients with a mental health condition have the same legal rights as …
Overdue
Robert Jones
Concerns: CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Response: The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will …
Responded
Margaret Walker
Concerns: Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Response (5 Boroughs Partnership NHS Foundation Trust): The Trust has reviewed its medicines policy, will issue further guidance on medicines reconciliation, has implemented Trust-wide initiatives for managing physical health and diabetes, developed diabetes guidelines, introduced Diabetes Link …
Responded
Lee Hollman
Concerns: The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Response (Royal College of General Practitioners): The RCGP and Royal Pharmaceutical Society will convene a multi-stakeholder group and establish a joint working group, including patients, to explore recommendations and develop a work program focused on shared …
Response (Riverside Surgery): Riverside Surgery met with the Horsham Community Mental Health Team to improve communication, discussed prescribing with the CCG, and has ongoing reviews for mental health patients, including specialist consultations, case …
Responded
Frederick Hall
Concerns: Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.
Overdue
Nicos Michael
Concerns: The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for hospital staff, and that electronic prescribing was not compulsory.
Response (East Kent Hospitals University): East Kent Hospitals University NHS Foundation Trust notes the coroner's concerns regarding the recording of a reported allergy to penicillin throughout the healthcare records, but states that concerns are based …
Responded
Rosemary Oladejo
Concerns: A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Response (Hillingdon Commissioning Group): Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors …
Response (Central North West London NHS Trust): Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance …
Responded
Mary Wanya
Concerns: Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
Overdue
Abiola Dosunmu
Concerns: Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.
Response (King's College Hospital NHS Foundation Trust): The Trust will refer the case to be included as a reminder in the formal teaching of Foundation doctors and has already shared the incident at departmental governance meetings. ED …
Responded
Margaret Connor
Concerns: Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.
Response (Heathers Nursing Home): The nursing home asserts it already meets required standards for equipment maintenance and staff training. They are implementing weekly wheelchair checks and providing staff with updated guidelines, including a wheelchair …
Responded
Linda Fisher
Concerns: Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): Blackpool Teaching Hospitals states that staff now perform a Mid Upper Arm Circumference calculation in line with the Malnutrition Universal Screening Tool (MUST) to assist is establishing an accurate weight, …
Responded
Courtney Mills
Concerns: Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.
Response (Portsmouth Hospitals NHS Trust): Portsmouth Hospitals NHS Trust states that the Clonidine medication was not prescribed by them and that the hospital would have supplied it if approached. They suggest that the Royal Pharmaceutical …
Response (Waterside Medical Centre): Waterside Medical Centre acknowledges the concerns and details their prior communications with the hospital and pharmacy regarding the patient's medication, suggesting the delay was due to the medication's limited availability …
Responded
Gary Bradshaw
Concerns: The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Response: Stockport NHS Foundation Trust has purchased the Patientrack electronic tracking system which is being piloted and evaluated, with phased rollout planned across the Trust, starting with vital sign input in …
Response (Department of Health): The Department of Health acknowledges the concerns and highlights existing national guidance (NICE, Royal College of Physicians) on early warning scores and the care of acutely ill patients, noting that …
Responded
Rainer Wickens
Concerns: Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.
Response (St Georges Healthcare NHS Trust): St George's Healthcare NHS Trust apologized for sub-optimal care and delays in a Serious Incident investigation. They have shared the investigation's learning outcomes, now investigate all cases of hospital-acquired thrombosis, …
Responded
Denise Prior
Concerns: Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Response (Western Sussex Hospitals NHS Trust): Western Sussex Hospitals NHS Trust has undertaken a thorough investigation and review and enclosed an action log setting out the action taken.
Responded
Thomas Maher
Concerns: Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Response (Central Manchester University Hospital NHS Trust): The hospital has implemented a new process to scan all records for deceased patients and those involved in high-level incidents into the electronic patient records system as a priority. Ward …
Responded
Daniel McCallum Keane
Concerns: The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Response (Department of Health): The Department of Health has passed concerns about a GP's conduct to the GMC and CQC; NHS England is addressing transfers of care with its patient safety expert group and …
Responded
John Cook
Concerns: Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
Response (NHS England): NHS England will not add telephone numbers to DNA CPR forms, but highlights existing policy requiring specific review dates and clear cancellation procedures and has requested the CCG to share …
Responded
Committee Recommendations (22)
#9 — Increase NHS digital and social media presence for reproductive health conditions consistently
Recommendation: With women and girls relying on online spaces and a proliferation of femtech apps to fill gaps in their knowledge of reproductive health conditions, the NHS should increase its own digital and social media presence in relation to reproductive health …
Gov response: It is unacceptable that some women have such poor experiences during procedures such as hysteroscopy, IUD (intrauterine device) fitting and cervical screening. Experiences of pain during these sorts of procedures can vary significantly from one …
Under Consideration
#8 — Improve NHS website with interactive tools, guidelines, accessibility, and mental health support
Recommendation: To supplement improvements in the provision of information on the NHS website, we recommend the inclusion of an interactive tool which can help women to determine whether they might have a reproductive health condition. We further recommend that information on …
Gov response: The government is committed to ensuring that women receive comprehensive, up-to-date information about diagnostic and treatment options for reproductive health conditions. Healthcare professionals are expected to provide women with detailed information ahead of any surgical …
Accepted
#7 — Enhance NHS website and app to be comprehensive, accessible, inclusive, and highly-visible
Recommendation: We know that many women and girls are using online spaces to get information and seek help while there are gaps in support in medical fields. It is therefore imperative that the NHS and trusted sources become a first-port-of-call to …
Gov response: As referenced in the report, RCOG is developing a guideline on the care of trans and gender-diverse adults in obstetrics and gynaecology. RCOG aims to publish this in 2026. The government is committed to delivering …
Under Consideration
#44 — Require Government to outline plans for upholding prison healthcare equivalence and integrating services
Recommendation: The Government must set out how it will ensure that the principle of equivalence in prison healthcare is upheld in practice. This should include a plan to address the operational barriers to healthcare delivery—such as staffing shortages, late receptions, escort …
Gov response: Accept. The Government is committed to ensuring that people in prison have access to an equivalent standard, range and quality of health care in prisons to that available in the wider community. This is reflected …
Accepted
#24 —
Recommendation: The DWP contact centre relied on telephone numbers in NHS patient records to call clinically vulnerable people who had not yet registered their needs. In some 375,000 cases out of the 800,000 people that the contact centre could not get …
Gov response: 6.2 Whilst the government agrees with the Committee’s recommendation, it does not agree with the conclusion that the lack of up to date phone numbers had a material impact on the government's ability to provide …
Not Addressed
#6 —
Recommendation: Missing or inaccurate telephone numbers in NHS patient records undermined government’s efforts to contact 375,000 people. The contact centre relied on telephone numbers in NHS patient records when calling people to check their needs. Over 20% of the 1.8 million …
Gov response: 2021. This is the Government’s response to the Committee’s report. Relevant reports • NAO report: management of the Industrial Strategy Challenge Fund – Session 2019-21 (HC 1130) • PAC report: Industrial Strategy Challenge Fund – …
Under Consideration
#1 — Ensure urgent and full implementation of IMMDS review recommendations 6 and 7 on patient records
Recommendation: Without records of which patient has undergone which procedure, or been prescribed which drug, the health system will continue to, in the words of the IMMDS review team, “fly blind”. We recommend that the Government urgently ensures that the accepted …
Gov response: . In the Government’s response to the IMMDS Review, published in July 2021, we accepted both recommendations 6 and 7 of the Review. Recommendation 6 covers the Medicines and Healthcare products Regulatory Agency’s (MHRA) role …
Accepted
#26 —
Recommendation: DHSC told us it is trying to improve contact information by asking clinically extremely vulnerable people to ensure their GP records are up to date and will continue to update the records as patients improve their record keeping with their …
Gov response: 6.3 During the shielding programme DHSC used shielding letters to encourage CEV people to update their contact details with their GPs, as this would allow the department to send more information via email and ensure …
Not Addressed
#13 —
Recommendation: The pandemic has again highlighted the role of high-quality data in enabling effective service delivery, monitoring and improvement. For example, due to missing or inaccurate telephone numbers within NHS patient records, the shielding programme was unable to follow-up letters to …
Gov response: 2: PAC conclusion: Government’s ability to make well-informed decisions and address issues as they arise during the pandemic has been hampered by slow progress in addressing longstanding issues with data and legacy IT. 2a: PAC …
Not Addressed
#22 —
Recommendation: Adult adoptees told us that one of the harms they experienced was the loss of their health records. The Government should introduce an adoption marker on health records so that requests for medical history can be sensitively handled and additional …
Response Pending
#10 — HMRC's internal system failures perpetuate incorrect letter delivery to affected taxpayer despite interventions.
Recommendation: We have raised this case with HMRC on several occasions in the past, but the taxpayer affected has continued to receive letters, including demands for payments.32 HMRC told us that addresses on its VAT system feed through into other systems, …
Gov response: 3.5 The government agrees with the Committee’s recommendation. Recommendation implemented 3.6 HMRC recognises the distress that misdirected letters can generate and will take immediate action to correct this when identified. The department would only use …
Accepted
#7 — Ensure accessible information on autism assessment process is available from pre- to post-diagnosis.
Recommendation: People with autism who may find it difficult to advocate for themselves can struggle to navigate the diagnosis process. The Government should work with NHS Trusts to ensure that information about the autism assessment process is accessible and available to …
Response Pending
#7 —
Recommendation: Results obtained from genomic testing must typically be considered in the context of an individual’s specific circumstance—including their symptoms, personal and family medical history and ethnicity—in order for the clinical significance of those results to be interpreted correctly. These personal …
Gov response: MHRA’s public consultation explores requirements around the information provided to users of DTC genomic tests and the outcome of this will help to inform future policy on how the tests are regulated.
Under Consideration
#3 —
Recommendation: Doctors may not be able to rely on patients to remember previous concussions or head traumas, especially if these happened at different times playing different sports. They must instead be able to rely on robust information that should be collated …
Gov response: The Government agrees in part with this recommendation. NHSX will continue to work with NHS England, NHS Improvement and NHS Digital to improve data quality and reporting by recommending the creation of codes for concussion …
Under Consideration
#6 — Include specific questions on honour-based abuse within the Domestic Abuse Risk Assessment tool
Recommendation: The Government must include specific questions on honour-based abuse in the Domestic Abuse Risk Assessment tool to help both victims and police officers identify risks confidently and accurately.
Gov response: The Government recognises the importance of ensuring that professionals recognise and understand HBA. There is a clear non-statutory definition which both the Home Office and the CPS already use: “an incident or crime involving violence, …
Under Consideration
#22 — HMRC's outdated Child Trust Fund records hinder tracing tool, making account retrieval challenging.
Recommendation: HMRC has not kept its records on Child Trust Funds up to date, affecting the quality of its tracing tool. This means young people trying to trace their accounts through the Government Gateway are receiving data from HMRC that have …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target Implementation date: Summer 2024 5.2 HMRC is exploring opportunities for publishing more timely information on CTFs. HMRC has reminded providers of the requirement to make returns …
Accepted
#2 — Retrospective mesh implant audit insufficient for capturing all adverse patient experiences
Recommendation: Although the retrospective audit of mesh implants is an encouraging first step, it will be unlikely to reflect and take into account all of the adverse effects women have experienced due to the nature of data used in the audit. …
Gov response: . NHS Digital undertook an audit of all pelvic floor surgery completed between 2006 and 2011 to generate a historical baseline of outcomes by procedure type and to support further research and analysis. The audit …
Accepted
#29 —
Recommendation: We urge the NHS to record the pain history of women undergoing procedures so that their needs can be prepared for. The NHS should be able to anticipate that someone who has previously struggled, for example with a smear test, …
Response Pending
#6 — Home Office Country Policy Notes show concerning inaccuracies affecting asylum claim decisions.
Recommendation: We share expert witnesses’ concerns about the performance of the Home Office Country Policy and Information Team and the accuracy and timeliness of Country Policy and Information Notes (CPINs). We heard several examples of outdated or otherwise inaccurate CPINs leading …
Gov response: In relation to the recommendations at paragraphs 69 and 70, we consider that the Country Policy and Information Team (CPIT) can maintain and update high quality CPINs in a timely manner and that a discrete …
Not Accepted
#19 — HMRC's data on unclaimed Child Trust Fund accounts remains significantly out-of-date.
Recommendation: HMRC’s understanding of accounts yet to be claimed is nearly two years out-of-date: its most recent estimate of the number of Child Trust Fund accounts yet to be claimed 22 Qq 27, 86; Hansard, HC written answer, Child Trust Fund, …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target Implementation date: Summer 2024 5.2 HMRC is exploring opportunities for publishing more timely information on CTFs. HMRC has reminded providers of the requirement to make returns …
Accepted
#21 — HMRC has not actively protected Child Trust Fund customers or monitored provider behaviour.
Recommendation: HMRC judged that, by 2013, the risk of tax loss from people opening Child Trust Funds they were not entitled to had fallen significantly. Few Child Trust Funds were opened after this point. We questioned whether HMRC had also assessed …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target Implementation date: Summer 2024 5.2 HMRC is exploring opportunities for publishing more timely information on CTFs. HMRC has reminded providers of the requirement to make returns …
Accepted
#20 — HMRC significantly reduced Child Trust Fund monitoring and compliance activity since 2013.
Recommendation: HMRC receives annual returns from providers with information about Child Trust Funds, including the number of accounts held and the number that have not been accessed by their owners. It told us that in the period when new accounts were …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target Implementation date: Summer 2024 5.2 HMRC is exploring opportunities for publishing more timely information on CTFs. HMRC has reminded providers of the requirement to make returns …
Accepted
CQC Inspection Actions (173) — showing 50 strongest matches
Verve Health
The service must ensure that service user records are legible and provide a contemporaneous account of all contact with the service user and relevant information in order to safely support each service user and manage risk.
Must Do
Haisthorpe House
The provider must ensure people who used services are protected from receiving unsafe care and treatment by maintaining accurate records about the care needs of each person living there.
Must Do
The Peter Gidney Neurodisability Centre
There was a failure to maintain accurate records of people's care.
Must Do
St John's Home
The provider must ensure that accurate and contemporaneous records are maintained in respect of service users.
Must Do
South Network
Information kept about people was not easily accessible, up to date or accurate. Regulation 17 (2) (c).
Must Do
Snowdrop Place Care Home
The registered person must maintain accurate, complete and contemporaneous records in respect of each service user.
Must Do
Russell Churcher Court
The provider must ensure that systems or processes are in place to ensure that records are kept up to date and accurate, and that the quality assurance system is effective in identifying issues.
Must Do
Promenade Care Home
The provider must maintain accurate records relating to people's care and support needs.
Must Do
Private Ultrasound Scan
The service must ensure staff maintain accurate and complete record in respect of each service user.
Must Do
Newland House
Records relating to the care and treatment of people using the service were not complete, accurate or up to date.
Must Do
Meadow Green
The provider must ensure good governance by maintaining accurate, complete and contemporaneous records in respect of each person who used the service, in line with Regulation 17 (2) (c).
Must Do
Lauren Court Residential Care Home
Systems and standards of record keeping had not been effective to sufficiently monitor and mitigate risks to the health, safety and welfare of people using the service. This placed people at risk of harm. This was a continued breach of …
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure safe care and treatment, including accurate care records, safe medicine management, appropriate risk assessments, proper recording and investigation of accidents and incidents, and sufficient staffing to prevent missed or late calls.
Must Do
George Edward Smart Homes
The provider must maintain an accurate, complete, and contemporaneous record in respect of each person.
Must Do
Forge House Services Limited
The registered manager should work with staff to improve staff recording, ensuring all care records display people's names, are dated and show who had written them, as not all care records displayed this information, making it difficult to accurately identify …
Should Do
Enstone House
People's records contained conflicting information. There were gaps on cleaning records.
Must Do
Cygnet Bury Hudson
The service must ensure that care records are contemporaneous and complete. Patient risk assessments must be updated following incidents and without delay.
Must Do
Chatham House
17 (2) (c) The provider had not ensured there were accurate, complete and contemporaneous records regarding the care and treatment provided in respect of everyone who lived at the home.
Must Do
BMI Southend Private Hospital
The provider must improve the quality and legibility of patient records.
Must Do
Applegarth Care Home
The provider must ensure that accurate, complete and up to date records are maintained in respect of people who use the service.
Must Do
Verve Health
The service must ensure that client records contain all relevant information in order to safely support each client and manage risk.
Must Do
Tregertha Court Care Home
The provider must ensure that accurate, complete, and contemporaneous records are kept in respect of each service user, specifically regarding food and fluid intake, including totals and assessed levels, to enable accurate monitoring of nutritional needs.
Must Do
St.Theresa's Nursing Home
The provider must ensure that care and treatment is provided in a safe way for service users, including ensuring care records are consistently completed, accurate, and updated to provide clear information on people's needs, including wound care and repositioning, and …
Must Do
St Paul's Lodge
The registered person must maintain accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided.
Must Do
Kingsley Nursing Home
The registered manager and provider failed to: 3. Maintain accurate, complete records of the care and treatment people received. 17 (2c)
Must Do
JDK Limited (Glenholme Care)
There were no processes in place to maintain records in an accessible and secure way. Information was not protected and was not accessible in emergency situations.
Must Do
Cheshire Hair Transplant Clinic Limited
The service must ensure staff keep complete and accurate patient records and store them safely.
Must Do
Attwood's Manor Care Home
The provider must ensure that records are accurate and provide sufficient guidance to staff to ensure people's needs are met.
Must Do
Darenth Grange Residential Home
The provider and registered manager failed to ensure a robust approach to keeping accurate records and improving the quality and safety of the service.
Must Do
Cygnet Bury Hudson
The provider must ensure there is an effective care record system in place to enable staff to access patient information in a timely manner.
Must Do
Continuity Healthcare Services Private Limited
The provider had not ensured that systems or processes operated effectively to assess, monitor and improve the quality of the service and mitigate the risks relating to the health, safety and welfare of service users. The provider had not maintained …
Must Do
Valewood House Nursing Home
People were at risk of receiving unsafe or inappropriate care and treatment because there was a lack of proper information about them and management records were not appropriately maintained.
Must Do
Redcot Lodge Residential Care Home
The provider must maintain accurate, complete and contemporaneous records in respect of each service user and assess, monitor and improve the quality of the service provided.
Must Do
Park Grange Care Home
Staff told us they felt the culture in the home had improved, and changes had been made which they felt were positive, however, we found there were records that were not accurate or contemporaneous. This meant the registered manager did …
Must Do
Waverley
The lack of clear up to date information in people's records and the lack of oversight of people's medicines, put them at risk of receiving unsafe care
Must Do
Unit 4 Cornishway Industrial Estate
Maintain securely records of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided;
Must Do
Trust Life Care
Audits had not always been effective in identifying issues found at this inspection. Records were not always complete, including mental capacity assessments.
Must Do
The Long Brook Residential Home
The provider had failed to maintain accurate, complete and contemporaneous records for each person living in the home.
Must Do
Suite 4, Jason House
The provider must ensure secure records are maintained.
Must Do
Shining Star Home Care Limited
Improvement was required in care documentation. People and relatives told us there was no accessible information which demonstrated what care had been agreed and how staff were to support them to keep them safe. People and relatives also told us …
Should Do
Psychiatry-UK LLP
The service should ensure consultants complete patient records in a timely manner after assessments.
Should Do
Psychiatry-UK LLP
The service must ensure there is monitoring and assurance that consultants complete care and treatment records in a timely manner.
Must Do
Personal Security Service
The provider must keep detailed records of patients’ care and treatment.
Must Do
People in Action - 132 Manor Court Road
17(2)(c) maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided;
Must Do
PHOENIX HEALTH KARE
Robust governance systems were not evident. Contemporaneous care records had not been maintained.
Must Do
Newtown House
The provider must ensure that systems and processes are operating effectively to assess, monitor and mitigate risks to the health and wellbeing of people, and that accurate, complete and contemporaneous records are kept about their care and treatment.
Must Do
Mr & Mrs T Grimshaw - 1 Taylor Avenue
Systems to audit the quality and safety of the service were not sufficiently robust. There were shortfalls in records relating to care and treatment of people, medicines, Mental Capacity and best interests decisions, recruitment and selection, and training.
Must Do
Moorview Care (Derby)
The provider failed to ensure systems and processes operated effectively to ensure compliance with legal requirements and maintain accurate and up to date records to promote the safety of people using the service.
Must Do
Millvina House
Some records were lacking information and were not always contemporaneous or accurate. Governance systems were still not always identifying or highlighting issues with service provision.
Must Do
Millvina House
The provider reviews their monitoring records and updates their practice to ensure records reflect the level of care given.
Should Do
HMICFRS Recommendations (4)
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
ICIBI Immigration Recommendations (2)
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should develop robust contingency plans to prepare for future crisis events. These plans must focus on the accurate collection and assurance of data.
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should prioritise and adequately resource the cleansing of applicant data relating to all Afghan resettlement schemes to provide as accurate a dataset as possible.
PPO Death in Custody Recommendations (89) — showing 50 strongest matches
The Head of Healthcare
The Head of Healthcare should ensure that the clinical record is an accurate reflection of significant interactions between staff and prisoners.
The Head of Healthcare
The Head of Healthcare to provide reflective and supportive supervision to the RMN who provided care to Mr Louis overnight on the 26 April 2023, and specifically to address the record keeping issues identified. To ensure that the RMN is …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff fully and accurately document all clinical interactions and decisions, in line with the standards specified by the General Medical Council and Nursing and Midwifery Council.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • prison staff record key information about their contact with prisoners on NOMIS, the prison records database, accurately and in a timely manner; and that • healthcare staff make contemporaneous records …
The Head of Healthcare
The Head of Healthcare should: • ensure that all healthcare staff are aware of the need to document all clinical care in a prisoner’s SystmOne record; and • carry out audits to ensure this is being done.
The Head of Healthcare
The Head of Healthcare should ensure daily clinical records for segregated prisoners capture and clearly reflect clinical thinking and assessment, in line with Nursing and Midwifery Council practice and communication standards.
The Head of Healthcare
The Head of Healthcare should ensure that all clinical assessments are fully documented in the patient’s medical record.
The Governor
The Governor should ensure that staff complete all relevant sections of a prisoner’s personal records and wing documents; and fully document all significant interactions and decisions.
The Head of Healthcare at HMP Frankland
The Head of Healthcare should ensure clinic letters are obtained and are available to view within the patient’s SystmOne medical records. This will ensure continuity of care and support the ongoing management of diagnosed health conditions.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff make detailed, timely and accurate entries in prisoners’ medical records in line with the Nursing and Midwifery Council’s Code and the Health and Care Professions Council’s Standards of Conduct.
The Head of Healthcare
The Head of Healthcare should ensure healthcare staff keep accurate and timely records of significant contacts.
The Head of Healthcare of HMP Liverpool
The clinical reviewer concluded that healthcare staff did not always adequately record their contact with prisoners. The Head of Healthcare will want to ensure this is improved.
The Governor
The Governor should ensure that staff fully document all significant interactions and decisions in prisoners’ personal records as well as other relevant documents; and implement robust auditing.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all relevant information about a prisoner is documented and shared appropriately and that there are robust quality assurances process in place to check this is happening routinely.
The Governor
The Governor should ensure that PERs are always updated to record relevant events.
Manx Care
Manx Care should implement electronic medication administration records.
The Director at Parc
The Director at Parc should ensure that staff assess risk based on all relevant information, including that held in medical records;
The Head of Healthcare
The Head of Healthcare should ensure that when healthcare staff undertake clinical assessments of acutely unwell patients, they complete a comprehensive assessment that includes obtaining a patient’s past medical history to inform a safe and comprehensive ongoing clinical treatment plan.
The Head of Healthcare
Records of initial health screens are accurate.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should formalise the way that PS incidents are assessed and the handover of care from healthcare to prison staff including: • The development and introduction of a PS assessment template for SystmOne, to include …
The NHS Commissioner for South Central
The NHS Commissioner for South Central should write to the Ombudsman, setting out how they intend to improve clinical record keeping at HMP Winchester.
The Head of Healthcare
The Head of Healthcare should ensure that all external hospital appointment locations are cross referenced against referral information/hospital confirmation letters to ensure patients are taken to the correct appointment location.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff share important information about a prisoner’s risk to himself with prison staff.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff accurately complete the medical information section of the escort risk assessment in full.
The Head of Healthcare
The Head of Healthcare should carry out an audit to ensure that healthcare staff appropriately consult prisoners’ full medical records when they raise concerns about their health.
The Governor and Head of Healthcare at HMP Lincoln
review processes to ensure staff consider PERs and SASH forms and record that they have done;
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review reception procedures to ensure that all staff supporting individuals and completing initial risk assessments have access to relevant information, including digital PERs, SASH forms and prison records.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review their information sharing protocol for prisoners with serious medical conditions such as epilepsy.
The Head of Healthcare
All referral forms include learning disability and autism in the list of significant conditions.
The Head of Healthcare
Staff use the alert function on SystmOne to include significant conditions such as ADHD and autism on the patients record.
The Head of Healthcare at HMP Drake Hall
The Head of Healthcare at HMP Drake Hall should ensure that healthcare staff take appropriate action in response to abnormal readings for blood pressure and cholesterol, in line with the National Institute for Health and Care Excellence (NICE) guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that there is a system in place for prisoners with chronic disease to be monitored and assessed effectively.
The Head of Healthcare
The Head of Healthcare should ensure there is a system in place for GPs to follow-up and action abnormal blood test results and blood pressure readings.
The Governor and The Head of Healthcare
The Governor and The Head of Healthcare should review the arrangements in place to ensure that information about changes to a prisoner’s risk and management is communicated promptly between operational and healthcare staff.
The Head of Healthcare
The Head of Healthcare should investigate why the reason for Mr Rigby’s GP appointment on 1 December 2023 was not included on the appointment ledger and take appropriate action.
The GP provider
The GP provider should ensure that all GPs are using the GMCs guidance on record keeping including when using remote consultation methods.
The Deputy Director of Immigration Prison Teams (North and South)
The Deputy Director of Immigration Prison Teams (North and South) should ensure that HOIE staff: share and record their contact with prisoners (and detainees) in prison records, including ACCT documents;
The Head of Healthcare
The Head of Healthcare should remind staff to ensure that patients understand the risks of refusing medical tests and clearly document this in medical records.
The Director of HMP Peterborough
The Director should ensure that all relevant interactions with prisoners, including those with the foreign national coordinator, are accurately recorded in the prisoner’s NOMIS record.
The Serco Contract Director for Prisoner Escort and Custody Services …
The Serco Contract Director for Prisoner Escort and Custody Services (PECS) must ensure that information is recorded in a detainee’s PER after every significant interaction, including any medical treatment given.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that accurate information is given from the scene of an emergency incident to staff in the control room about the condition of a prisoner.
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with multiple NHS numbers have their records merged within 24 hours of arriving at Wandsworth.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: are fully competent in using the National Early Warning Score (NEWS2) effectively; complete full and accurate clinical observations; follow protocols for clinical escalation in line with NEWS2 and sepsis pathways; and …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should examine Reception practices and devise a plan to ensure that all relevant staff read and appropriately respond to information contained in Person Escort Records when processing prisoners.
The Head of Healthcare
The Head of Healthcare should check and ensure that all staff, including agency staff, have been trained to access the digital Person Escort Record.
The Head of Healthcare
The Head of Healthcare should conduct an urgent review of the following areas of mental healthcare delivery at Wakefield: ▪ develop a protocol for disseminating transfer handover information, within a centralised email system, not to an individual staff member’s email, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare professionals completing segregation unit health screens have access to the prisoner’s medical history and are always given the opportunity to speak to the prisoner.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at high risk of complications from COVID-19 in line with national guidance. Key actions and decisions should be fully documented in prisoners’ medical and personal records.
The Head of Healthcare
The Head of Healthcare should ensure that newly arrived prisoners with long-term medical conditions are managed appropriately, including: • prompt referrals to the GP at the prison; • offering a further opportunity for a secondary health screen if a prisoner …
The Director and Head of Healthcare (HMP Northumberland)
The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: healthcare staff complete the medical section of …
IOPC Learning Recommendations (6)
Stop and search, Harlesden - Metropolitan Police, October 2018
The IOPC recommends that Metropolitan Police Service officers ensure that all detainees are informed as soon as practicable if the charges against them change and that this is reflected in the relevant documentation. Our investigation found that a man was …
Recommendation - Devon and Cornwall Police, August 2020
The IOPC recommends that Devon and Cornwall Police take whatever action is necessary to ensure hostage negotiators are aware that BWV or voice recording equipment is being used throughout the duration of negotiations to ensure that all conversations and decisions …
National recommendations - National Police Chiefs' Council, August 2020
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should give due consideration to records of historic convictions still held on microfiche and how they will be managed within the new system that will be replacing the Police National …
National recommendations - National Police Chiefs' Council, August 2020
The IOPC recommends that the National Police Chiefs’ Council (NPCC) writes to all forces to determine for each whether their Police National Computer (PNC) training and/or guidance is up to date with the College of Policing guidance and specifically whether …
Concerns for man's welfare - Cleveland Police, May 2022
The IOPC recommends that Cleveland Police should implement a system or protocol to ensure that potential discrepancies in address – in which a reporting person provides an address that does not exactly match those available to select on Force systems …
Police contact with a woman and her partner, prior to the woman’s …
The IOPC recommends the Metropolitan Police Service (MPS) should amend the ‘Gathering Evidence’ section of its Domestic Abuse (DA) Policy. Currently it says, ‘Officers must ensure that they gather as much information as practicable… and record the information gathered and …
NAO Audit Recommendations (10)
Protecting and supporting the clinically extremely vulnerable during lockdown
NHSE&I and NHS Digital should set out how they will improve the accuracy of patient telephone numbers to improve the speed of communication with patients;
Accepted
DWP Report on Account 2022/23
DWP should: b develop the capability to record detected underpayments across all benefits as part of any planned updates to its IT systems.
Rejected
DWP Report on Account 2022/23
DWP should: b perform more in-depth analysis to determine the root cause of a greater number of detected underpayments; and
Partially accepted
DWP Report on Account 2022/23
b establish an ?early warning system? to record types of underpayment errors that happen repeatedly and take action before they develop into significant issues. As part of setting up this system DWP should: ? encourage frontline staff to refer large …
Partially accepted
DWP Report on Account 2022/23
a work with HMRC to review the level of assurance over the integrity of National Insurance records and identify ways to reduce error in the records.
Accepted
The Department for Environment, Food and Rural Affairs annual report and accounts …
I also recommend that EA develop more robust controls over the input and maintenance of data in its property, plant and equipment records.
Accepted
The Department for Environment, Food and Rural Affairs annual report and accounts …
I recommend that EA, with support from the Department, carries out a review of the data quality and cleanse the property, plant and equipment records prior to embarking on a large revaluation exercise.
Accepted
Environment Agency Annual Report and Accounts 2021-22
I also recommend that the Environment Agency develops more robust controls over the input and maintenance of data in its property, plant and equipment records.
Accepted
Environment Agency Annual Report and Accounts 2021-22
I recommend that the Environment Agency carries out a review of the data quality and cleanse the property, plant and equipment records prior to embarking on a large revaluation exercise.
Accepted
The Affordable Homes Programme since 2015
Discuss with Homes England and the GLA what data gaps it has and how to address them in a proportionate way. This includes data to support its economic modelling, evaluate benefits and ensure adequate oversight
Accepted
IMB Annual Reports (9)
Gatwick, Stansted, Luton and Lunar House (2022)
The IMB report for Gatwick, Stansted, Luton airports and Lunar House covers the period ending January 2022, noting a significant increase in detained individuals. While C&C officers are generally compassionate, the Board highlights ongoing concerns about the inadequacy of holding rooms at all locations for increasing numbers, extended stays, and vulnerable individuals. Key issues include limited space, lack of natural light, absence of showers, and persistent problems with access to onsite healthcare professionals and timely medication.
PRISON
Key concerns
Dover (2022)
The Dover Independent Monitoring Board's 2021 report details critical issues at the Tug Haven, Kent Intake Unit (KIU), and Frontier House Short-Term Holding Facilities. While some initial improvements were noted in induction processes and staff interactions, the facilities were largely unsuitable for their purpose, particularly Tug Haven, which routinely held detainees overnight in overcrowded, unheated tents with inadequate sleeping, washing, and food provisions. Significant concerns were raised about poor hygiene, brief and ineffective medical screenings leading to undetected serious injuries, and excessive lengths of stay, causing distress and confusion among detainees, including vulnerable families and children.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2022)
The IMB report for Kent Coast STHFs in 2022 documented a year of unprecedented small boat arrivals, leading to significant overcrowding and challenges across Western Jet Foil, Kent Intake Unit, and Manston. A primary concern was the widespread practice of detaining individuals for periods far exceeding the statutory 24-hour limit in conditions deemed unsuitable, particularly at Manston. While staff were commended for their compassion, critical issues persisted regarding lack of privacy for sensitive interviews, inadequate basic provisions, poor sleeping arrangements, and insufficient information for detainees about their processing journey.
PRISON
Key concerns
Lincoln (2024)
HMP Lincoln, a Category B reception and resettlement prison, continues to treat prisoners fairly and humanely despite challenges from its Victorian infrastructure and high transient population. Positive aspects include improved cleanliness, effective neurodiversity support, and dedicated staff. However, key concerns persist regarding maintenance backlogs, slow access to specialist mental health facilities, property management issues, and inadequate support for remand prisoners and vulnerable populations.
PRISON
Key concerns
Littlehey (2024)
HMP Littlehey, a Category C training prison for sex offenders, generally maintained a safe and humane environment with positive developments like a new wing and in-cell phones. Despite commendations for healthcare and resettlement efforts, the IMB remains critically understaffed, hindering its monitoring capacity. Key challenges include persistent cell sharing, poor property transfer management, healthcare resource deficits, and inadequate educational provision, many of which are repeated concerns.
PRISON
Key concerns
Pentonville (2025)
HMP Pentonville, a category B local prison, faced significant challenges including severe overcrowding, crumbling infrastructure, and a rise in drug use. While some improvements were noted in safety management, the Board raised serious concerns about inhumane living conditions, inadequate key work provision, and delays in support for vulnerable prisoners. The report highlights the impact of capacity pressures on regime delivery and resettlement efforts, stressing the need for urgent investment in the prison's fabric and resources.
PRISON
Key concerns
Ashfield (2025)
The reporting period for HMP Ashfield was marked by significant change, including a new contract with Serco and the establishment of a new therapeutic community. While the Board found the prison generally safe, with high prisoner satisfaction in feeling secure, there were increases in self-harm and violence incidents compared to unusually low previous year figures. Key concerns include persistent staffing challenges impacting morale, inadequate social and dementia care for the aging population, and issues with the new split-week regime affecting purposeful activity and pay.
PRISON
Key concerns
Scotland and Northern Ireland short-term holding facilities (STHF) (2025)
This report monitors Short-term Holding Facilities (STHFs) in Scotland and Northern Ireland, highlighting significant variations in standards and persistent concerns despite positive staff interactions at times. Key issues include a lack of independent oversight for Controlled Waiting Areas, the continued mixed-sex detention at Larne House, and inconsistent, often inadequate, healthcare provisions, particularly the removal of prescription medication. The Board also raised concerns about substandard accommodation, excessively long detention periods in unsuitable conditions, and a strikingly low number of formal complaints, indicating systemic barriers to raising grievances.
PRISON
Key concerns
Durham (2022)
HMP Durham, a reception and resettlement prison, housed 976 prisoners at year-end, with 61.6% on remand, operating above its certified capacity. The Board commends staff for managing a challenging environment, noting that 93% of prisoners feel safe. Key concerns include persistent overcrowding, the increasing time unsentenced prisoners spend on remand due to court backlogs, and inadequate access to dentistry and certain induction processes. The report highlights improvements in staff attendance at key meetings and UoF monitoring, but also calls for better embedding of BWVC use and addressing regime limitations affecting education and resettlement.
PRISON
Key concerns
IMB Recommendations (25)
Wymott (2020)
Management of the delivery of healthcare appointment slips remains problematic (see paragraph 6.2.4). Can a more reliable method be found?
Governor / Director
Bristol (2024)
Healthcare concerns are one of the top issues raised with the IMB by prisoners at HMP Bristol. Are you satisfied that the contract with Oxleas NHS Foundation Trust meets the needs of the prisoners?
Governor / Director
Portland (2020)
Checks need to be put in place to ensure that critically unwell prisoners, suffering significant health problems, cannot be unilaterally transferred. Should this ever be necessary, it should not happen without prior negotiation with the receiving establishment and the provision of up to date and comprehensive medical records.
HMPPS
Thameside (2023)
Address the continued deficiencies of on wing CMS which have a major impact on prisoners’ lives.
Governor / Director
Guys Marsh (2023)
Records of prisoner learning achievements can be piecemeal and inaccurate. Has the Prison Service conducted any quality assurance on these records and if so, is the Prison Service confident that these records are fit for purpose?
HMPPS
Thameside (2025)
The Director should implement measures to improve record keeping across departments, including key worker entries, meeting minutes, action trackers, CSIP paperwork, and accurate recording of foreign national prisoner language levels.
Governor / Director
Send (2025)
The Board would like to see a process in place for healthcare professionals to record why prisoners decline breast screenings (6.1).
Governor / Director
North West and Midlands STHF (2025)
For the seventh year in succession, the Board repeats its concern at the lack of proper procedures that would allow the Home Office or its contractors to routinely provide detained individuals with access to their own medication. The Board considers the welfare of some of those who have been detained may have been adversely affected by this situation, depending on …
Home Office
Exeter (2020)
Will the Prison Service undertake to improve the arrangements within the prison estate and with its transport contractors in giving prisoners’ property a higher priority and ensure better care and management of property on transfer between prisons? (See paragraph 5.8).
HMPPS
Exeter (2020)
Will the Prison Service increase support given to prisons regarding how the required data collection and reporting processes can be practically applied to make a positive impact on the operation of the prison and the lives and experiences of prisoners? (See paragraph 4.2).
HMPPS
Durham (2020)
What can be done to improve prison staff entries into prisoner portfolios?
Governor / Director
Wormwood Scrubs (2021)
When a prisoner refuses to attend a hospital appointment, can the reason for that refusal be noted on the relevant documentation?
Governor / Director
Usk and Prescoed (2021)
As reported in our 2020 report, up to fifty per cent of the OASys documents received in HMP Usk vary in quality with the “start custody” section either remaining blank or the quality of recording falling short of expectation. See 7.3.3
HMPPS
Bristol (2022)
The actual waiting times for access to specialist mental health services experienced by prisoners appear to be longer than reported. This is due to the design of the reporting rules covering different stages of the pathway. Will the rules be reviewed so that the reported figures accurately reflect the total time waited?
Ministry of Justice
Thameside (2024)
The Board has concerns about how some ACCT documents are being completed, especially the lack of healthcare attendance at first case reviews (FCRs) in over half of the audited documents seen.
Governor / Director
Pentonville (2024)
The 2022 Prisoners’ Property Framework has yet to have any positive impact on the transfer of property between prisons. Will HMPPS commit to an evidence-based review of the Framework?
HMPPS
Onley (2024)
As the Board has stated in every annual report for many years, missing, mislaid and delayed prisoner property continues to be a problem, particularly on transfer between prisons. The aim of the Prisoners’ Property Policy Framework is to improve the management of property, but this has not been met. The manual, paper-based system is error-prone and inefficient. It relies on …
Ministry of Justice
Five Wells (2024)
How can the healthcare department improve prisoner understanding of changes to their medication?
Governor / Director
Wealstun (2025)
As referenced in previous reports, how will the Governor ensure that information in an ACCT file only includes paperwork for one week whilst archiving and storing the remainder? The size of some files make them difficult to navigate by staff and IMB members, thus potentially failing to see the continuity clearly.
Governor / Director
Styal (2025)
Are there any plans to decrease the amount of paperwork required for assessment, care in custody and teamwork (ACCT) assessments and observations through digitalisation and possibly the use of hand-held technology, which may reduce potential duplication or human errors?
HMPPS
Yarl’s Wood (2020)
The Board recommends that the systems and procedures in place for processing small boat migrants are more careful and thorough to ensure that those arriving at IRCs do so accompanied by the correct personal information.
Home Office
Thorn Cross (2022)
To ensure that sending prisons complete records fully (6.6.7) (4.0.2).
HMPPS
Foston Hall (2023)
A significant number of healthcare appointments are missed. What can be done to improve communication to prisoners about appointments and enable their attendance?
Governor / Director
Hewell (2024)
Are the current health needs assessments, including mental health assessments, still fit for purpose given the changing demographics of the prison population?
HMPPS
Yarl’s Wood IRC (2023)
R35 medical reports should be audited. The IMB should have access to oversight of this process.
NHS / Healthcare Provider
Article 2 Learning Points (18)
— LP B
The Medical Record should be properly updated within 24 hours of any action taken or decisions made.
PPG
— LP 1
A brief review of the available SystmOne medical record should be made by staff prior to performing initial health-screening to validate the answers made to the template-driven questions.
PPG
Accepted
— LP 16
Everyone seeing a prisoner should write in a record, either in SystmOne or the prison record. The counsellor and substance misuse worker should write in SystmOne and the Chaplain in the prison record (P-NOMIS). It is good practice to have regular case conferences for complex cases, with documentation of an …
HMP Altcourse and HMPPS
Accepted
— LP 12
Staff employed by Birmingham and Solihull Mental Health NHS Foundation Trust should be reminded of the specific requirements in PSI 73/2011, P-NOMIS to add case notes about behavioural issues or which detail specific issues that might help the care of the offender by staff generally.
PPG
Accepted
— LP 10
There should be an effective system for following up requests for medical records if these fail to arrive.
PPG
Accepted
— LP 14
Greater priority should be given to seeking back records from previous establishments, particularly for those prisoners with complex needs or challenging behaviour, where assessments from a previous sentence may be particularly useful.
The Governor
Accepted
— LP Healthcare 6
Individual staff log-in details should not be shared or used by other members of the healthcare team to make entries to the electronic Patient Record.
Healthcare Provider
— LP Healthcare 5
Paper documentation which is generated and subsequently scanned to the electronic Patient Record should clearly identify the location, date, time and author along with their designation.
Healthcare Provider
— LP Healthcare 3
The opening of an ACCT and a summary of key issues and actions from ACCT reviews should be documented in the clinical record to ensure that this information is easily accessible to members of the healthcare team. In addition, the ACCT flag function should be used to ensure that all …
Healthcare Provider
— LP 16
(a) We recommend that guidelines be developed and implemented at HMP Pentonville as to what should and shouldn’t be recorded in ACCT and SystmOne. These guidelines could be integrated into existing documentation. To make it easier for staff, we recommend that these guidelines include examples of what should and shouldn’t …
HMPPS
— LP 2
The CARATS teams should record information about their interviews with prisoners in unit history sheets, and share assessments with staff who are managing prisoners, particularly when an ACCT (formerly F2052SH) process has been opened. These records should be available when required for any future investigations.
HMPPS
Implemented
— LP 2
We recommend that PECS and GEOAmey review the access for staff in the custody suite at Southampton Magistrates’ Court to update computerised or manual records to ensure it is sufficient to enable compliance with requirements.
PECS and GEOAmey
Accepted
— LP 2
We recommend that there should also be a brief but informative entry on the electronic record.
HMPPS
Accepted
— LP 17
To make better use of pre‐existing information, we recommend that psychiatric assessment guidelines used on HMP Pentonville’s Healthcare unit reference the need to source and consider the results of medical and psychiatric assessments that may have been conducted by other institutions.
PPG
Accepted
— LP 12
We recommend that HMP Pentonville’s Healthcare unit reviews its use of ‘Special Observation forms’ and clarifies what value, if any, they are adding to the care and management of a prisoner who is on an observation regime.
PPG
Accepted
— LP 11
Managers at HMP Birmingham should remind prison staff in contact with prisoners of the importance of documenting events in a prisoner’s Prison National Offender Management Information System record.
The Governor
Accepted
— LP 14
We are aware that the project to improve the effectiveness of the Person Escort Record is a work in progress and that our observations may have been overtaken as the new form is piloted and developed. However, we invite the Project Group on the Person Escort Record to consider the …
HMPPS
Accepted
— LP Healthcare 4
The date and time of an individual’s transfer to secondary care and discharge back to prison should be documented in the clinical record. This should include any required actions which are identified on discharge from secondary care.
Healthcare Provider
Detention Investigations (2)
Assessment of government progress in implementing the report on the … — Rec 17
SystmOne templates should be urgently amended so that detainee healthcare records no longer identify detainees as prisoners.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 18
NHS England should continue to roll out staff training on SystmOne/HJIS, and should make sure that patient consent is consistently recorded by conducting a national case fle audit and ensuring that this is a mandatory feld in HJIS.
Immigration Detention
PHSO Casework Decisions (204)
P-001344 — South Tees Hospitals NHS Foundation Trust
Mr N complained that the South Tees Hospitals NHS Foundation Trust recorded incorrect information in his medical record and failed to amend or delete this when he requested it to do so.
NHS in England
Mar 2022
P-004727 — An independent provider in the Redbridge area
Ms N complains that notes for another patient were added to her medical records following after an appointment at a community care provider. She says this resulted in incorrect treatment being scheduled and delays in the correct treatment being provided.
NHS in England
Jan 2026
P-001385 — Lewisham and Greenwich NHS Trust
Ms E complains that Lewisham and Greenwich NHS Trust gave her incorrect treatment, documented incorrect information in her records relating to medication, and lost her ECG reports from 24 December 2018. She also says the Trust have failed to respond to her further letter of concerns.
NHS in England
May 2022
P-001446 — A medical practice in the London Borough of …
Mr Y complains that the Practice did not advise his late father's nursing home that he should be hospitalised, did not inform him of his father's deteriorating health and did not keep adequate records of a GP consultation in April 2020.
NHS in England
May 2022
P-002247 — Bromley Healthcare
Ms A complains Bromley Healthcare has false information in its records about an appointment in February 2019.
NHS in England
Oct 2023
P-003026 — County Durham and Darlington NHS Foundation Trust
Ms J complains the Trust included false and damaging information about her in her daughter’s cognitive assessment report.
NHS in England
Oct 2024
P-003578 — A practice in the Halton area
Mr J complains the Practice recorded inaccurate and incorrect information in his medical records between September 2021 and May 2023.
NHS in England
May 2025
P-003710 — A practice in the Croydon area
Mr F complains about the treatment he received from his GP Practice from January – July 2024. Mr F says the Practice did not communicate the results of his blood pressure readings and delayed acting on the results of specialist referrals.
NHS in England
Jul 2025
P-001196 — University Hospitals Sussex NHS Foundation Trust
Mrs W complained the Trust discounted she had cauda equina (compressed nerves in the spinal chord) and failed to take her medical history into account. She also complained the Trust unnecessarily stopped her pain medication.
NHS in England
Oct 2021
P-001373 — The Dudley Group NHS Foundation Trust
Mr O complained that after his surgery at The Dudley Group NHS Foundation Trust, information about his heart rhythm was not shared with him in a correct and timely manner.
NHS in England
Apr 2022
P-001403 — Liverpool Women's NHS Foundation Trust
Mrs A complains the Trust made an administrative error stating she had undergone three excision surgeries, when she only had one. She also complains about the impact this then had on her care and treatment.
NHS in England
May 2022
P-001410 — A medical practice in the Torbay area
Ms U complains the Practice incorrectly recorded her liver function test results and she was not advised that her test results were abnormal.
NHS in England
Jun 2022
P-001742 — University Hospitals of North Midlands NHS Trust
Mr A complains the Practice did not correctly examine his mother, order the right tests or refer her to the Trust quickly. He complains the Trust did not record or treat her speech and mental health issues, said his mother was fine and discharged her too soon.
NHS in England
Jan 2023
P-001842 — The Priory Hospital
Miss O complains the Hospital recorded her weight falsely and this affected her physical and mental health.
NHS in England
Jan 2023
P-001720 — A practice in the Wirral area
Mr O complains the Practice gave him wrong information about his test results and about its planned course of treatment.
NHS in England
Jan 2023
P-001774 — A practice in the Staffordshire area
Mr E complains the Practice did not correctly diagnose his wife's symptoms or give the right treatment. He also complains the Practice did not give warning advice or update his wife's records fully.
NHS in England
Feb 2023
P-001866 — University Hospitals Sussex NHS Foundation Trust
Mr A complains about the Trust's dermatology care and says it did not update his records correctly.
NHS in England
Mar 2023
P-001861 — A practice in the East Riding of Yorkshire …
Mrs I complains about the Practice saying it did not tell her she was becoming diabetic, although it did several blood tests.
NHS in England
Mar 2023
P-002005 — East Kent Hospitals University NHS Foundation Trust
Mrs A complains the Trust outsourced the MRI and CT scans to a third party who reported the results incorrectly. She also complains the Trust missed an opportunity to diagnose Mr A's brain tumour and to give him palliative treatment sooner and it did not give him pain relief.
NHS in England
May 2023
P-003895 — A GP practice in the Leicester area
Ms U complains the Practice did not tell her about a high platelet count in her blood test results in 2018, it did not do the correct tests to find out why the count was high and the GP who saw her in 2020 laughed about her condition.
NHS in England
Sep 2023
P-002322 — Manchester University NHS Foundation Trust
Ms R complains the Trust added an incorrect clinical code to her records after a hospital admission in 2013 and gave inconsistent explanations for this.
NHS in England
Nov 2023
P-002509 — A practice in the Rochdale area
Mr and Mrs C complain about the service the Practice gave Mrs C in 2022 when she tried to confirm a diagnosis of premenstrual dysphoric disorder (PMDD). They also complain the Practice sent them another patient’s information when they asked for Mrs C’s medical records.
NHS in England
Mar 2024
P-002641 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs T complains the Trust did not take her symptoms seriously when she went to A&E in August 2022 and also about the accuracy of its record keeping.
NHS in England
May 2024
P-002605 — London North West University Healthcare NHS Trust
Mr L complains the Trust failed to give him some test results despite him trying different ways to get these.
NHS in England
May 2024
P-002691 — Gloucestershire Hospitals NHS Foundation Trust
Miss F complained about the record keeping around her father’s restraint and the care the Trust provided before discharging him.
NHS in England
Upheld
Jun 2024
P-002979 — Mersey Care NHS Foundation Trust
Ms P complains about care and treatment provided by the Trust in 2022 saying it communicated false information in her discharge summary and report, it failed to provide good physical or mental healthcare and forced her to attend follow up care. She also disagrees with its diagnosis.
NHS in England
Sep 2024
P-003001 — North London NHS Foundation Trust
Mrs U complains the Trust included information in her father’s discharge summary and occupational therapy report that was untrue and in conflict with his care assessment. She says the Trust took information from her father’s wife as fact, ignoring what her father said and what was written in his notes. …
NHS in England
Sep 2024
P-003155 — Manchester University NHS Foundation Trust
Mrs A complains the Trust have not recorded a correct diagnosis for her heart following an echocardiogram.
NHS in England
Nov 2024
P-003109 — West Hertfordshire Teaching Hospitals NHS Trust
Mrs B complains about care and treatment provided to her husband in February 2023. She says the doctor did not ask the right questions or do the correct tests, misdiagnosed and missed a blood clot in her husband’s lungs and wrote misleading information in the records.
NHS in England
Nov 2024
P-003299 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs W complains about the Trust’s care after her father was admitted in July 2021 for a suspected heart attack. She complains the Trust did not check his medical record and gave him a large dose of medication that his GP had stopped and it only allowed two visitors.
NHS in England
Jan 2025
P-003270 — North Bristol NHS Trust
Mrs L complains that after she contacted the Trust, before her breast screening appointment in March 2020, it incorrectly recorded that she declined to attend and did not send her a further invitation. She is also concerned it has not acknowledged it made an error and has not apologised or …
NHS in England
Partly Upheld
Jan 2025
P-003342 — Northern Care Alliance NHS Foundation Trust
Miss A complains that she had a scan in 2021 that showed signs of lung cancer. She says doctors only told her about this in August 2024.
NHS in England
Feb 2025
P-003592 — A practice in the North East Derbyshire area
Mrs A complains the Practice did not do a physical examination to assess her ongoing severe pain over a five month period and it refused to prescribe pain relief. She also complains it failed to include crucial clinical information in a referral letter to neurosurgery.
NHS in England
Jun 2025
P-003729 — Portsmouth Hospitals University NHS Trust
Mr O complains about the inpatient care his wife received from the Trust from May to July 2021. This included premature discharge, inappropriate medication management and poor record keeping.
NHS in England
Upheld
Jul 2025
P-003740 — A practice in the Cheshire West and Chester …
Miss I complains the organisations removed diagnoses from her medical records, shared her information with third parties and failed to upload her records to an electronic system.
NHS in England
Aug 2025
P-003942 — Oxford University Hospitals NHS Foundation Trust
Ms T complains about care Mr R received at a hospital between March 2020 and December 2020. She complains the Trust did not offer appropriate treatment for Mr R’s prostate cancer, did not provide physiotherapy treatment and communicated poorly about a significant diagnosis.
NHS in England
Upheld
Sep 2025
P-004087 — East Kent Hospitals University NHS Foundation Trust
Mr N complains about his father's care in September 2022 saying the Trust did not treat him promptly when he first went to the emergency department or keep accurate records. He also complains about the Trust's complaint handling.
NHS in England
Sep 2025
P-004068 — A practice in the Ribble Valley area
Ms X complains about the care and treatment to her by her local GP Practice between December 2023 and July 2024. She complains that the Practice provided inadequate care and a lack of essential treatment, and they failed to accurately complete records following consultations with her.
NHS in England
Sep 2025
P-004297 — University Hospitals Birmingham NHS Foundation Trust
Miss T complains the Trust failed to manage her mother's diabetes , did not meet her dietary needs, and was not monitoring her as it should. Ms T also complains the Trust's communication was poor and it incorrectly recorded her mother's cause of death on the death certificate.
NHS in England
Partly Upheld
Nov 2025
P-004459 — Northern Care Alliance NHS Foundation Trust
Mrs B complains the Trust failed to provide appropriate care to her husband in November 2019. She says it cancelled tests, missed referrals, had inaccurate records, and poor communication.
NHS in England
Dec 2025
P-004483 — Worcestershire Acute Hospitals NHS Trust
Mr N complains about the Trust’s record keeping of his medical records around how he obtained his HIV infection.
NHS in England
Dec 2025
P-004742 — Stockport NHS Foundation Trust
Mr P complains the Trust performed a fasciotomy to treat his Dupuytren’s disease affecting his left little finger which was not appropriate to do so due to the severity of his condition. Mr P complains of inaccuracies in his medical records.
NHS in England
Jan 2026
P-004594 — Dorset Healthcare University NHS Foundation Trust
Mr U complains that the Dorset Healthcare University NHS Foundation Trust refused to remove what he believes to be inaccurate information from his medical records.
NHS in England
Jan 2026
P-001069 — Taunton and Somerset NHS Foundation Trust
Mr O complains the Trust gave him a ‘false negative’ diagnosis of emphysema. He complains that following a computerised tomography (CT) scan, the clinic letter sent to his GP omitted important information which affected his treatment from that point onwards. Mr O also complains the Trust claimed he did not …
NHS in England
Not Upheld
May 2021
P-001114 — Southern Health NHS Foundation Trust
Mrs I complains about Southern Health NHS Foundation Trust. She complains that it changed her mental health referral from urgent to routine without telling her, and that it recommended medication which her clinical records say she cannot have. Mrs I also complains it did not provide her with individual psychotherapy …
NHS in England
Partly Upheld
Sep 2021
P-001220 — Royal Free London NHS Foundation Trust
Mrs G and Mr G complain about the inadequate care and treatment the Trust provided to their late mother and grandmother when she was admitted to hospital with a fractured hip. They also have concerns about the Trust's record-keeping, communication and in the issuing of the death certificate.
NHS in England
Partly Upheld
Oct 2021
P-001229 — University Hospitals Birmingham NHS Foundation Trust
Mr L complains about the way doctors discharged his father from hospital in February 2020. He also says the discharge documentation was not detailed enough.
NHS in England
Dec 2021
P-001491 — Leeds Teaching Hospitals NHS Trust
Mr R complains that the Trust misdiagnosed him as it did not detect changes in his Magnetic Resonance Imaging (MRI) scans between December 2019 and September 2021.
NHS in England
Aug 2022
P-001489 — An Inpatient Service in the Darlington area
Mr I complains that the Inpatient Service shared his medical information with his employer without consent, and that some of his medical records are inaccurate.
NHS in England
Aug 2022
P-001560 — Moorfields Eye Hospital NHS Foundation Trust
Miss O complains that the Trust incorrectly diagnosed a condition in her left eye and therefore gave her the wrong medication.
NHS in England
Sep 2022
LGO / SPSO Decisions (464)
NIPSO-202001704 — Belfast Health and Social Care Trust
Error created uncertainty and caused patient upset, but did not impact on the care she received.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
NIPSO-29583 — Lurgan Medical Practice
We found that a medical assessment performed during a home visit was carried out in line with good medical practice, but that the GP should have recorded what had been discussed with the patient and her family, and what they should do if her symptoms did not improve.
NIPSO (NI Public Service…
Health & Social Care
Dec 2020
21-001-259a — Central London Community Healthcare NHS Trust (21 001 …
Summary: We found fault with the record keeping by the district nurses and the way they ordered dressings. We also found there was a lack of a multidisciplinary team approach to Mr B’s care. We found the Council did not action its safeguarding enquiry immediately and it was not open …
LGO (Local Government & …
Health
Upheld
Apr 2022
21-015-380c — Dignus Healthcare Ltd (21 015 380c)
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-015-380b — Coventry & Warwickshire Partnership NHS Trust (21 015 …
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
21-015-380a — Dignus Healthcare Ltd (21 015 380a)
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-015-380 — Coventry City Council
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Adult Care Services
Not Upheld
Sep 2022
21-018-569c — The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-018-569a — Norfolk & Suffolk NHS Foundation Trust (21 018 …
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Health
Not Upheld
Oct 2022
201405121 — Scottish Prison Service
Mr C raised a number of complaints with the prison about disciplinary reports that were noted on his computerised record. Mr C asked the prison to provide copies of the relevant paperwork in relation to each report or remove them from his record. The prison confirmed that there was no …
SPSO (Scottish Public Se…
Prisons
Upheld
Aug 2015
201508104 — Grampian NHS Board
Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner. Following investigation, we were of the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2016
201810096 — Scottish Prison Service
Mr C attended his brother's integrated case management (ICM) case conference. This meeting is held each year when the prisoner and those involved in supporting them get together to discuss their sentence management. A document used to minute the discussions is then shared with all attendees. On receiving this document, …
SPSO (Scottish Public Se…
Prisons
Upheld
Jul 2020
202301188 — Lothian NHS Board - Acute Division
C complained that Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2024
NIPSO-202002199 — Northern Health and Social Care Trust
We upheld a complaint from a woman who said that her late mother should not have been discharged from Antrim Area Hospital.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
PSOW-202307000 — Betsi Cadwaladr University Health Board
Mr A complained about the lack of timely dental communication, updates and engagement by Betsi Cadwaladr University Health Board’s (“the Health Board’s”) orthodontic services in relation to his son, Child B. He questioned how the orthodontist services could have made decisions about his son’s dental care without seeing him. Child …
PSOW (Public Services Om…
Health
May 2024
PSOW-202402126 — Cwm Taf Morgannwg University Health Board
Miss T complained that Cwm Taf Morgannwg University Health Board has not provided the necessary treatment to deal with her chronic pain. The Ombudsman found that whilst the Health Board had responded to Miss T’s concerns informally, it failed to correctly escalate her complaint in accordance with its complaints process …
PSOW (Public Services Om…
Health
Sep 2024
PSOW-202404887 — Betsi Cadwaladr University Health Board
Mrs A complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to update her or respond to her second complaint about her late daughter’s care and treatment. She said that 16 months after she submitted the complaint, the Health Board said that it was unable to respond to …
PSOW (Public Services Om…
Health
Nov 2024
PSOW-202409193 — Cardiff and Vale University Health Board
Ms A complained that Cardiff and Vale University Health Board cancelled her thyroidectomy surgery on the day of the procedure because she was a smoker. Ms A was removed from the waiting list and referred for smoking cessation. Ms A said that the Health Board had not previously advised her …
PSOW (Public Services Om…
Health
May 2025
22-004-890 — Surrey County Council
Summary: We will not investigate this complaint about the Council failing to keep accurate records and of having an inappropriate comment in Mr X’s records. This is because there is not enough evidence of fault and significant injustice to justify an investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-016-387 — Plymouth City Council
Summary: Mr X and Miss Y complained that despite granting conditional approval for a vehicle crossing the Council has since rejected their application. The Council’s failure to ensure the information available on its website regarding vehicle crossings is accurate and up to date regarding its processes is fault. This fault …
LGO (Local Government & …
Transport And Highways
Upheld
Aug 2022
22-008-171 — Torbay Council
Summary: We will not investigate Mrs X’s complaint the Council has issued an education and health care plan containing inaccurate personal information about Ms Y and without her consent. There is insufficient injustice. Mrs X can go to the Information Commissioner if she has data protection concerns. We cannot lawfully …
LGO (Local Government & …
Education
Oct 2022
23-013-143 — London Borough of Enfield
Summary: Miss X complained about how the Council has handled her housing application. She also complains about the Council’s poor communication and said it had failed to properly consider her and her mother, Ms Z’s medical information. We find the Council was at fault. This caused them significant distress. The …
LGO (Local Government & …
Housing
Upheld
May 2024
201300749 — Scottish Prison Service
Mr C, who is a prisoner, complained about aspects of a review of his supervision level, after he was involved in a fight at the prison. He previously had a low level of supervision but, following the fight, this was reviewed and increased to a high level. He complained that, …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Sep 2013
201203949 — A Medical Practice in the Highland NHS Board …
Mr C had a history of heart problems and was previously a patient of the practice. He said that, while he was their patient, they twice lost blood samples although the explanation given was that they were lost by the hospital. Mr C also complained that on one occasion when …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2013
201300588 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison had not amended an intelligence report (adverse information obtained by the Scottish Prison Service that affects an individual prisoner) on him to accurately reflect the outcome of suspected drug use, and that the prison had not passed an accurate version …
SPSO (Scottish Public Se…
Prisons
Upheld
Dec 2013
201300285 — Scottish Prison Service
Mr C complained about the handling of an intelligence entry (adverse information obtained by the Scottish Prison Service (SPS) that affects an individual prisoner) from some years ago. He was concerned that he was not told about the entry at the time. Our investigation found that the SPS had handled …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2013
201302276 — A Medical Practice in the Greater Glasgow and …
Mrs C complained that she saw a nurse at her medical practice twice to report a lump on her breast but nothing was done. In between these appointments, she attended a mobile breast screening clinic for a mammogram (an x-ray of the breast) and, after being recalled for further investigations, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2014
24-018-961 — Sefton Metropolitan Borough Council
Summary: Mrs B complained about the standard of care her mother, Mrs X, received when the Council organised a placement at Lakeside View Care Home. We uphold the complaint, having identified several areas of fault with the care provided to Mrs X, and inaccurate care records. There was also fault …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
201804064 — A Medical Practice in the Tayside NHS Board …
Mrs C complained that the practice had failed to properly investigate a series of complaints she had made about entries in her and her children's medical records. Mrs C believed the practice's conclusions were unreasonable given the available evidence. Mrs C also complained that the practice failed to communicate appropriately …
SPSO (Scottish Public Se…
Health
Not Upheld
Oct 2020
201901728 — Greater Glasgow and Clyde NHS Board - Acute …
A few hours after a surgical procedure, C underwent a second operation due to an internal haemorrhage (a loss of blood from a blood vessel that collects inside the body). Following the second operation, C complained to the board about the documenting of their operations, the estimation of their blood …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2021
NIPSO-21053, 21181, 21182 — Northern Ireland Ambulance Service TrustBelfast Health and Social …
The Chief Executives of three health trusts have apologised after an error in recording a patient’s date of birth led to him being confused with another patient.
NIPSO (NI Public Service…
Health & Social Care
Jul 2021
NIPSO-202001919 — Northern Health and Social Care Trust
A woman complained about how long it took the Northern Health Trust to provide her late son with a routine test for heart disease, and about its subsequent failure to monitor his condition.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2023
NIPSO-202002149 — Northern Health and Social Care Trust
The Northern Trust failed to keep proper records of a patient's food intake, and didn't provide him with insulin after he experienced an episode of hypoglycaemia.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
NIPSO-202005762 — GP
A woman claimed that if her late husband’s weight loss been investigated properly his cancer may have been detected sooner. We found it was a ‘significant failure in care and treatment’ that his GP didn’t send him for further diagnostic treatment.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2025
PSOW-202004109 — Hywel Dda University Health Board
Mrs M complained about the care and treatment that her daughter, Ms D, received from the Health Board’s Mental Health Services following the onset of 2 acute psychotic crises. Mrs M complained that, on 20 December 2019: 1.The Health Board failed to arrange for a Section 12 approved doctor to …
PSOW (Public Services Om…
Health
Upheld
Apr 2022
PSOW-202208013 — Cardiff and Vale University Health Board
Mr S complained that Cardiff and Vale University Health Board failed to pick up a referral for his father. Mr S said that it was only discovered when he contacted the Health Board for an update and an explanation as to why it was missed was not provided. The Ombudsman …
PSOW (Public Services Om…
Health
Jun 2023
21-003-942 — London Borough of Hounslow
Summary: The complainant complained the Council failed to include in her late mother’s financial assessment the valuation it had placed on her home resulting in her being liable for the full costs of her residential care. The complainant says the Council failed to seek an independent valuation as provided for …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jan 2022
22-010-600 — Tameside Metropolitan Borough Council
Summary: We will not investigate Mrs B’s complaint about the Council’s failure to keep her informed about her daughter’s, Ms C’s needs, or inaccuracies contained in Ms C’s hospital Passport. This is because further investigation by us could not add to the Council’s response.
LGO (Local Government & …
Adult Care Services
Dec 2022
21-018-192 — Lancashire County Council
Summary: We find fault with the Council. The Council did not keep accurate records about what was discussed with Miss S before she agreed to go to a Care Home. It also did not arrange funding with the local Integrated Care Board (ICB) to cover the interim period Miss S …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-021-262 — East Sussex County Council
Summary: We will not investigate Mr X’s complaint about inaccurate information being included in Section D of his child’s Education, Health, and Care (EHC) plan. This is because an investigation would not lead to any further findings or outcomes as the Council has appropriately remedied the injustice caused by the …
LGO (Local Government & …
Education
May 2024
24-006-460 — Medway Council
Summary: We will not investigate this complaint about data recorded about the complainant and his family by the Council in a assessment document. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. There is no evidence of …
LGO (Local Government & …
Children S Care Services
Jul 2024
24-022-755 — London Borough of Redbridge
Summary: We will not investigate Mr X’s complaint that the Council recorded and shared inaccurate information in a report to the courts and failed to respond to the Information Commissioner’s request for information. The law prevents us from investigating what happens in court, including the preparation and contents of court …
LGO (Local Government & …
Children S Care Services
May 2025
24-012-078 — London Borough of Croydon
Summary: Mrs X complained the Council provided an inadequate refuse service for her clinical waste. The Council was at fault for poor record keeping, failing to investigate Mrs X’s concerns appropriately and for providing inaccurate information about changes to its service. This caused Mrs X avoidable frustration and uncertainty for …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
25-003-564 — London Borough of Hammersmith & Fulham
Summary: We will not investigate this complaint about a missing social services record as it is best dealt with by the Information Commissioner’s Office and the courts.
LGO (Local Government & …
Other Categories
Jun 2025
201102068 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS) failed to explain the outcome of a risk assessment he had undergone. Mr C said that he had asked the psychologist who completed the risk assessment for further information, but that she failed to respond. We were, however, unable to find …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Apr 2012
201204718 — A Medical Practice in the Tayside NHS Board …
Mr C complained about the care and treatment provided to him by the medical practice. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix, we were unable to take this complaint further, and …
SPSO (Scottish Public Se…
Health
Jun 2013
201204712 — A Medical Practice in the Tayside NHS Board …
Mr C complained about the care and treatment provided to him by the medical practice. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix, we were unable to take this complaint further, and …
SPSO (Scottish Public Se…
Health
Jun 2013
201100100 — Borders NHS Board
Mr C made three complaints about the treatment that the board's mental health service gave his brother (Mr A). Mr A had long term mental health difficulties including paranoid schizophrenia (a condition that may cause hallucinations, delusions and muddled thoughts and behaviours). He lived independently and had been prescribed Modecate …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2013
201204914 — A Medical Practice in the Ayrshire and Arran …
Mr C went to the practice because he had lower back and left leg pain, together with numbness. After his second visit, he was referred for physiotherapy, and then to hospital for a consultant opinion and an MRI scan (a scan used to diagnose health conditions that affect organs, tissue …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2013
201204913 — Ayrshire and Arran NHS Board
Mr C visited a hospital accident and emergency department (A&E) with lower back and left leg pain and increasing periods of numbness. He was discharged with an appointment to see a consultant twelve days later. Within a short time of being discharged, however, Mr C returned to hospital as he …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2013