Inadequate hospital care for learning disabled

The Head of Healthcare

The Head of Healthcare should ensure that all prisoners with learning disabilities are clearly recorded, staff receive relevant learning disability training and follow NHSE/I guidance for prisoners with learning disabilities.

The Governor

The Governor should ensure that staff are: aware of autism and the range of issues that prisoners with autism may face; and aware of prisoners with a communication support plan in place and refer to it before interacting with the …

The Head of Healthcare

The Head of Healthcare should ensure that in a medical emergency, the patient is moved to an appropriate area where they can be fully assessed and treated.

The Head of Healthcare

The Head of Healthcare should ensure that prisoners who are unwell and require clinical monitoring are reviewed overnight.

Nottingham (2023)

HMP/YOI Nottingham experienced a reduction in self-harm and use of force, but assaults on both prisoners and staff increased. Key challenges included inadequate provision for prisoners with severe mental health issues and disabilities, significant healthcare staff shortages, and concerns over the complaints system and property loss. The report also highlighted regime curtailments due to staff training and uncertainty for IPP prisoners.

PRISON Key concerns

Northumberland (2023)

HMP Northumberland, a category C prison, is generally assessed as safe, despite a slight increase in violent incidents and self-harm. Significant progress has been made in primary healthcare provision, staff-prisoner relationships, and a revised regime aims to boost purposeful activity. However, the Board holds severe and repeated concerns regarding the profound lack of appropriate mental health provision, leading to the inappropriate use of segregation for acutely unwell prisoners, alongside challenges with education attendance and property management.

PRISON Key concerns

Lancaster Farms (2025)

HMP Lancaster Farms, a Category C resettlement prison, continues to provide a largely safe environment for its 560 prisoners, with positive initiatives like the complex care unit and CrossFit program. However, significant concerns persist, particularly around healthcare provision, including long waiting times and issues with medication and data transparency. The Board also highlights problems with property management during transfers, a rise in prisoners on the restrictive basic regime, and continued challenges in placing prisoners with complex mental health needs in specialist facilities.

PRISON Key concerns

Onley (2025)

HMP Onley, a Category C prison, experienced a challenging year with significant increases in violence and self-harm incidents. Key concerns include high levels of illicit substances, poor living conditions, and unacceptable waiting times for healthcare. Despite some positive developments in key worker delivery and resettlement initiatives, staffing shortages and backlogs in offender management continue to hinder progression.

PRISON Key concerns

Erlestoke (2025)

HMP Erlestoke is a Category C training and resettlement prison with an operational capacity of 512. The Board observed improvements in healthcare attendance and use of force scrutiny, alongside a decrease in staff turnover. However, significant concerns remain regarding the deteriorating healthcare building, the pervasive availability of illicit substances, and the inadequate provision for vulnerable prisoners, including the elderly and those requiring essential medication on transfer.

PRISON Key concerns

South and East 2022-23 Short Term Holding Facilities (STHF) (2023)

This IMB report for South and East STHFs highlights critical concerns over prolonged detention periods in facilities designed for short stays, often leading to inhumane conditions due to a lack of adequate sleeping facilities, showers, and privacy. While staff sensitivity is commended, issues such as facility maintenance delays, overcrowding, and accessibility for vulnerable individuals are prominent. Recommendations focus on facility reviews, provision of essential amenities like sleeping mats, and improved transfer efficiency.

PRISON Key concerns

North Sea Camp (2023)

HMP North Sea Camp, an open Category D male resettlement prison, maintained a safe and humane environment with generally positive staff-prisoner relationships and good healthcare provision during the reporting year. Key challenges include persistent delays caused by Community Offender Managers impacting ROTL and Parole Board hearings, the insecurity faced by IPP prisoners, and ongoing issues with accommodation quality, property transfers, and routine maintenance due to contract failures. The Board noted diligent efforts in resettlement, purposeful activity, and equality, supported by robust internal programs.

PRISON Key concerns

Springhill (2023)

HMP Springhill, an open Category D prison, faced significant challenges in 2023, primarily driven by a substantial increase in its population to 330. The Board highlighted deteriorating infrastructure, a persistent rat infestation, and widespread staff shortages impacting healthcare, education, and resettlement efforts. While some safety metrics like self-harm remained low, assaults rose, and concerns persist regarding accommodation quality, prisoner pay, and the effectiveness of the complaints system, hindering the prison's core resettlement purpose.

PRISON Key concerns

Bure (2024)

HMP Bure is a Category C prison for men convicted of sexual offenses, housing 641 prisoners with an operational capacity of 643. The IMB found it to be a generally calm and safe environment with good staff-prisoner relationships and well-supported elderly prisoners. Key concerns include the lack of work and purposeful activity opportunities for the current population, the need for IPP re-sentencing, and insufficient funding for resettlement services. The Board also noted an increase in self-harm incidents and issues with archaic adjudication recording.

PRISON Key concerns

Moorland (2025)

HMP/YOI Moorland faced significant pressures this year from a high turnover of prisoners and early release schemes, yet reception staff performed well. While positive developments include improved ACCT records, successful translation programs, and some regime liberalisations, the report highlights concerns over increased violence, self-harm, and use of force. Key areas for development include addressing overcrowding (single cells as doubles), improving healthcare quality and access, and enhancing rehabilitation and purposeful activity for prisoners, particularly for IPPs.

PRISON Key concerns

Eastwood Park (2021)

Our concerns continue about a prisoner with an acquired brain injury who has been continuously segregated at Downview and Eastwood Park prisons for 1,202 days by the end of this reporting period. In response to correspondence your predecessor stated that ‘the truth is that the right environment simply doesn’t exist within the prison system to cater for her unique needs’. …

Other

Werrington (2025)

Why are children with complex needs sent to Werrington when there are no specialist facilities available? And why is it so time-consuming to get them transferred? How will this be improved?

HMPPS

Wandsworth (2022)

The previous report noted that the new healthcare facility, when it opens, will not include any cell accommodation to relieve pressure on the totally inadequate Jones and Addison units. HMIP recently described the units as ‘not a fit place to care for seriously unwell patients’. Funding was secured for the refurbishment of six cells in Addison, and work began in …

HMPPS

Altcourse (2022)

Once again, the Board has highlighted the plight of severely mentally unwell men being contained in totally unsuitable conditions and without access to appropriate treatment for long periods of time before being transferred to appropriate secure units.

Ministry of Justice

Ashfield (2023)

With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of specialist custodial centres?

HMPPS

Ranby (2024)

Prisoners have been constantly located in the CSU due to their complex and challenging behaviour and mental health issues. Why is it taking so long to transfer these prisoners to an appropriate medical establishment?

Other

Lewes (2020)

The Board, once again, is concerned at the number of prisoners seen over the reporting year who are seriously mentally unwell and kept in conditions, be it accommodation standards or the regime, which are entirely unsuitable for their care or rehabilitation. The same applies to many of the prisoners with learning or other disabilities. Will the minister undertake a comprehensive …

Ministry of Justice

Eastwood Park (2020)

The IMB at Eastwood Park has raised concerns with the minister about a prisoner with an acquired brain injury who had been segregated in HMP Downview and HMP/YOI Eastwood Park for 827 days up to the end of this reporting period. While we understand that normal location is not a possible alternative in her case, because of her behaviour, is …

Ministry of Justice

Dovegate (2021)

Accelerate plans for the conversion of the in-patient unit in healthcare to provide consultation and treatment rooms adequate for the number of residents in the prison. Should it be decided not to proceed with the above, then urgently upgrade the inpatient bath/shower room.

Governor / Director

Norwich (2022)

Will the Minister please explain why this continues to be the case and what plans there are to move them out of HMP/YOI Norwich?

Ministry of Justice

Norwich (2022)

The Board asks the minister ‘Why are these men still being kept in custody?’ (referring to men with severe mental health issues and/or learning disabilities who should be in establishments that can properly address their issues).

Ministry of Justice

Long Lartin (2022)

The healthcare centre (HCC), and in particular the inpatient unit and facilities for disabled prisoners, are in need of urgent modernisation. Will the Prison Service give priority to complete refurbishment and improvement of the in-patient unit and replacement of the stairlift?

HMPPS

Eastwood Park (2022)

After 1,484 days in continuous segregation a prisoner with an acquired brain injury was transferred from Eastwood Park to a medium secure NHS facility in September 2022 for assessment. What discussions has the Minister had with the Department of Health to ensure that adequate secure facilities for women with acquired brain injuries are available to avoid such inhumane treatment of …

Other

Guys Marsh (2020)

There is a national concern about the increase in the number of prisoners with poor mental health, and those with educational or physical needs. How will the minister work with relevant departments in a coordinated way to facilitate a better strategy for the humane incarceration of all prisoners with complex needs?

Ministry of Justice

Bullingdon (2020)

Will the prison service review the provision for older prisoners in the prison estate as a whole, bearing in mind their increasing numbers and the examples in this report (see below, 5.4.7, 6.3.3) of unequal treatment for this group?

HMPPS

Whatton (2022)

Will the Prison Service, once again, consider substantial refurbishment or replacement of the healthcare facilities so that they match those expected in the community?

HMPPS

Heathrow Immigration Removal Centre (2022)

In our 2021 annual report, we urged the Minister to fund a complete replacement of the core lift in Harmondsworth, a lift which is essential for enabling detainees with mobility issues to access healthcare. A replacement lift was not commissioned and during 2022 the central lift was out of order on numerous occasions over a five-month period. We continue to …

Ministry of Justice

Lincoln (2023)

Given the issues associated with the Victorian infrastructure of the prison, what alternative provisions are being considered for the increasing numbers of frail elderly, particularly those with dementia, end of life care and disabled prisoners?

HMPPS

Heathrow Short Term Holding Facility (2020)

[Becket House] The Home Office should ensure that new holding rooms in a facility in Warehouse K, London E16 will include the provision of showers. (para. 21.6).

Home Office

Heathrow Short Term Holding Facility (2020)

[London Heathrow Airport T5] The Home Office should provide a shower in Terminal 5 to comply with the National Holding Room Standards (para. 3.9).

Home Office

Eastwood Park (2020)

Will the Governor review the suitability of mattresses, especially for older prisoners and those with health needs?

Governor / Director

Norwich (2021)

Are there plans for refurbishment of the healthcare unit and L Wing to provide a more suitable environment for the ill and elderly?

HMPPS

Frankland (2021)

Given the ageing prison population and a growing number of prisoners being diagnosed with dementia, can consideration now be given to providing an appropriate physical environment for this group of prisoners along with suitably qualified care workers (para 6.4)?

Ministry of Justice

Foston Hall (2021)

Are there plans to address: the inadequate accommodation for the provision of healthcare

HMPPS

Erlestoke (2021)

Will the Minister consider providing more facilities to meet the needs of those within the autistic spectrum, unsuitable for location in a normal prison environment?

Ministry of Justice

Frankland (2022)

HMP Frankland’s provision for pharmacy on the lower older wings is not fit for purpose. Does the Prison Service have a solution to this critical situation?

HMPPS

Winchester (2023)

Given the issues associated with the Victorian infrastructure of the prison, what alternative provisions are being considered for the increasing numbers of elderly and disabled prisoners?

Ministry of Justice

Garth (2023)

For many years, complaints have been registered about the very inadequate waiting area in the healthcare unit. This needs to be addressed urgently.

HMPPS

Lincoln (2024)

Given the issues associated with the Victorian infrastructure of the prison, what alternative provisions are being considered for the increasing numbers of frail elderly, particularly those with dementia, end-of-life-care and disabled prisoners?

HMPPS

Hewell (2024)

Will the Minister invest more in the maintenance and updating of prisons, to end inhumane and unsanitary conditions, and to meet the needs of an ageing population with related health and mobility challenges?

Ministry of Justice

P-001113 — Northern Lincolnshire and Goole NHS Foundation Trust

Mrs L complained about the Trust’s decision not to provide further treatment to her daughter, Miss A, who had COVID-19. She also complains the Trust would not allow her in the hospital to be with Miss A who had learning difficulties.

NHS in England Not Upheld Sep 2021

P-001256 — A medical practice in the Gloucestershire area

Mrs V complained about the care the Practice and Trust provided to her brother, Mr V, for symptoms and illnesses she believes may have contributed to his sudden death. Mrs V believes her brother's autism and mental health needs were not adequately addressed.

NHS in England Partly Upheld Aug 2021

P-001454 — Barnsley Hospital NHS Foundation Trust

Mrs E complains that hospital staff did not properly account for her husband’s dementia when caring for him during his admission. Mrs E says the Trust decided Mr E was ready to be discharged despite not having the right care in place, and told her that Mr E was ready …

NHS in England Not Upheld Jul 2022

P-002763 — Lancashire Teaching Hospitals NHS Foundation Trust

Miss T complains staff at the Trust did not keep her mother adequately hydrated, check her pressure areas and keep her oxygen saturation within the target range.

NHS in England Partly Upheld Jul 2024

P-003084 — Sheffield Teaching Hospitals NHS Foundation Trust

Ms N complains the Trust discharged her brother, who was autistic and non verbal, from hospital before his infection had cleared and without suitable provision for his care.

NHS in England Oct 2024

P-001343 — North Bristol NHS Trust

Mrs A complained about the inpatient care and treatment her late mother received from the North Bristol NHS Trust from December 2020 until her death in February 2021.

NHS in England Partly Upheld Mar 2022

P-004558 — Manchester University NHS Foundation Trust

Mr U complains on behalf of his wife, Mrs U, about Northern Care Alliance NHS Foundation Trust and Manchester University NHS Foundation Trust between December 2022 to February 2023. He says Mrs U was not adequately mobilised, prescribed medications without adequate instructions, inappropriately taken off anticoagulant medication, was not adequately …

NHS in England Dec 2025

P-002588 — County Durham and Darlington NHS Foundation Trust

Mrs T complains about how the Trust looked after her father. She says it did not keep the family updated, it did not investigate his problems fully, it did not give him the right food and drink, it did not keep him mobile and attempt to rehabilitate him and it …

NHS in England Partly Upheld May 2024

P-002635 — Epsom and St Helier University Hospitals NHS Trust

Miss T complains the Trust did not provide her father with enough nutrition during his admission in June and July 2022. She also complains the Trust delayed referring her father to a dietitian and it did not attempt nasogastric feeding or look for an alternative way to feed him.

NHS in England Upheld May 2024

P-002909 — Mid Cheshire Hospitals NHS Foundation Trust

Mrs O complains about the Trust’s care and treatment of her father. She says it failed to refer him to the Speech and Language Therapy (SLT) team soon enough after his admission, it inappropriately changed her father’s fluid provision, it failed to treat her father as nil by mouth and …

NHS in England Upheld Sep 2024

P-003086 — Chesterfield Royal Hospital NHS Foundation Trust

Miss Y complains the Trust left her father alone twice in one day when they knew he was at risk of falling and this led to him falling twice.

NHS in England Oct 2024

P-003645 — Barnsley Hospital NHS Foundation Trust

Ms G complained about the care her mother received as an inpatient and the Trust’s communication with her family at the end of her life.

NHS in England Jul 2025

P-003676 — Barts Health NHS Trust

Mr H complains about how clinicians at a hospital managed his mother's worsening health. He also has concerns about communication and cleanliness.

NHS in England Jul 2025

P-003666 — Great Western Hospitals NHS Foundation Trust

Mr F complains about a lack of physiotherapy and poor nursing care his father received at the Trust. He also complains staff gave his father antibiotics he was allergic to.

NHS in England Jul 2025

P-003755 — North East and North Cumbria Integrated Care Board

Mr C complains about the ICB’s decision that his son was not able to have his carers with him while he was in hospital in February 2024.

NHS in England Aug 2025

P-004140 — Oxford University Hospitals NHS Foundation Trust

Miss A complains about the aftercare her daughter received following a kidney and pancreas transplant at the Trust. She says the Trust should have been caring for her daughter in the intensive care unit and did not monitor her heart rate or carry out appropriate observations.

NHS in England Oct 2025

P-004247 — London North West University Healthcare NHS Trust

Mr N complains about the care and treatment the Trust provided to his sister Ms L. He complains the Trust did not make reasonable adjustments and did not promptly diagnose or treat Ms L's lung infection.

NHS in England Nov 2025

P-004472 — An independent provider in the Cornwall area

We consider there have been failings with the way in which Psychiatry UK (PUK) conducted Miss T’s autism assessment. This includes the time it took for PUK to complete its assessment, the input from Miss T’s parents, and not considering her masking and poor working memory. We consider this has …

NHS in England Upheld Dec 2025

P-004715 — County Durham and Darlington NHS Foundation Trust

Ms U complained about a fall her father, Mr L, sustained whilst in hospital under the care of the Trust. She complained this fall led to Mr L's death.

NHS in England Upheld Jan 2026

P-004640 — The Hillingdon Hospitals NHS Foundation Trust

Miss B complains about the care and treatment The Hillingdon Hospitals NHS Foundation Trust provided to her mother, Ms J, during an inpatient admission from 27 April 2020 to 4 May 2020. She specifically complains about falls assessments, nursing care, communication and complaint handling.

NHS in England Upheld Jan 2026

P-001111 — Gateshead Health NHS Foundation Trust

Mr T complains the Trust did not assess or treat his injured foot correctly and there were delays in care. He complains this led to him suffering infection requiring the amputation of a bone in his foot.

NHS in England Partly Upheld Sep 2021

P-004561 — Milton Keynes University Hospital NHS Foundation Trust

Mrs Y complains about the care and treatment her mother, Mrs D, received from Milton Keynes University Hospital NHS Foundation Trust between May and July 2023. She raises concerns about delays in pain relief and fluids, poor hygiene practices, inadequate post-surgery pain management, failures in fall prevention, and rough handling …

NHS in England Partly Upheld Jan 2026

P-003834 — Northern Care Alliance NHS Foundation Trust

Mr A complains the Trust did not give him the right care and treatment for his badly swollen elbow.

NHS in England Jul 2023

P-002837 — Liverpool University Hospitals NHS Foundation Trust

Mrs I complains about the care and treatment her mother received at the Trust in January and February 2023. Mrs I complains that staff left her mother in a corridor for up to 30 hours, staff showed a general lack of compassion and no sensitivity towards her age-related macular degeneration …

NHS in England Aug 2024

P-003370 — University Hospital Southampton NHS Foundation Trust

Mr R complains about the lack of care provided to his father by University Hospital Southampton NHS Foundation Trust (the Trust), which resulted in a fall on 25 May 2023.

NHS in England Partly Upheld Feb 2025

P-003419 — Hull University Teaching Hospitals NHS Trust

Mr A complains the Trust did not make arrangements for his son, Mr C, to monitor his own blood glucose levels using his wearable sensor during the hospital admission. He says the Trust did not properly manage Mr C’s diabetes in the way it should have.

NHS in England Partly Upheld Mar 2025

P-003453 — Gateshead Health NHS Foundation Trust

Mrs H complains the length of time her niece had to wait to use the toilet after staff had given her an enema was wrong. She said this led to compartment syndrome. She also says the Trust did not do adequate care and risk assessments to keep her niece safe …

NHS in England Partly Upheld Mar 2025

P-004282 — North Cumbria Integrated Care NHS Foundation Trust

Mrs A complains about how doctors and nurses treated her mother during an admission to hospital. She is specifically concerned about surgical procedures, hydration and nutrition and the response to her mother’s deterioration.

NHS in England Not Upheld Nov 2025

P-004731 — George Eliot Hospital NHS Trust

Mrs C complains about her mother's care and treatment during her admission from February 2024 to May 2024. She complains the Trust did not provide adequate nursing care and discharged her when she should have remained in hospital.

NHS in England Jan 2026

P-004666 — Hampshire Hospitals NHS Foundation Trust

Mr R complains the Trust failed to treat and care for Mrs P's bed sores which she developed while under the care of the Trust. He also complains that the Trust failed to communicate the bedsores to the family and the district nurse team upon discharge.

NHS in England Jan 2026

P-004690 — University Hospitals Birmingham NHS Foundation Trust

Mrs A complains about the care and treatment her late mother, Mrs L, received from a hospital in Birmingham between July and August 2023. She says her mother was injured due to being placed on a faulty chair and that her discharge care package failed.

NHS in England Jan 2026

P-001890 — Sandwell and West Birmingham Hospitals NHS Trust

Mr R complains the Trust did not give his father appropriate pureed food when he was an inpatient between August and September 2021.

NHS in England Mar 2023

P-002550 — West Hertfordshire Teaching Hospitals NHS Trust

Mrs A complains that during her husband's admission the Trust did not get him out of bed enough or allow him to walk, it did not show empathy or an understanding of his dementia when attempting to wash him and it left him flat and in head blocks for longer …

NHS in England Apr 2024

P-002900 — King's College Hospital NHS Foundation Trust

Mrs A complains about the care and treatment her mother received from the Trust in the months before her death. Mrs A says the Trust failed to admit her mother in a timely manner and did not provide sufficient hydration or nutrition during her admission.

NHS in England Aug 2024

P-003065 — Royal Cornwall Hospitals NHS Trust

Mrs E complains the Trust failed to provide her mother with appropriate nutrition, oral care and delirium treatment between December 2022 and January 2023.

NHS in England Oct 2024

P-003331 — Blackpool Teaching Hospitals NHS Foundation Trust

Mrs D says her husband died from his pneumonia as he was cold, due to inappropriate clothing in hospital.

NHS in England Feb 2025

P-003636 — Manchester University NHS Foundation Trust

Mrs U complains her father, Mr L, was not adequately supervised in hospital and received fluids in an unsafe way. She also complains about medication not being stopped, and delays in inserting a feeding tube.

NHS in England Partly Upheld Jun 2025

P-003647 — University Hospitals Dorset NHS Foundation Trust

Miss T complains about the Trust’s actions before her godfather had a fall in hospital.

NHS in England Partly Upheld Jun 2025

P-003725 — East Sussex Healthcare NHS Trust

Mr O complains about his care and treatment in March 2024. He complains about being kept in hospital and how an iron and blood transfusion were carried out.

NHS in England Jul 2025

P-004322 — University Hospitals Birmingham NHS Foundation Trust

Mr A complains the Trust's falls management was poor, and it had a poor post‑incident response after his father fell in March 2023. He also complains there was a failing in the Trust's use of sedatives and the Trust imposed restrictions on his father without proper safeguards.

NHS in England Nov 2025

P-001306 — Mid Yorkshire Hospitals NHS Trust

Miss U complains that staff at the Mid Yorkshire Hospitals NHS Trust did not provide her late father with appropriate nutritional support and intravenous fluids, which she thinks contributed to his death.

NHS in England Not Upheld Feb 2022

P-001499 — United Lincolnshire Hospitals NHS Trust

Mr E complains that the Trust did not appropriately manage his late wife's nutritional needs and correctly administer her regular medication when she was an inpatient.

NHS in England Aug 2022

P-002392 — Leeds Teaching Hospitals NHS Trust

Mr E complains the Trust delayed diagnosing his wife's cancer, caused internal damage during an operation, did not properly manage his wife’s hygiene, failed to give medication to his wife, failed to stop blood thinning medication before a planned operation and lost his wife’s wedding and engagement rings.

NHS in England Jan 2024

23-013-609b — Royal Free London NHS Foundation Trust - North …

Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …

LGO (Local Government & … Health Upheld Jun 2025

23-013-609a — Royal Free London NHS Foundation Trust - North …

Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …

LGO (Local Government & … Health Upheld Jun 2025

NIPSO-201912943 — Belfast Health and Social Care Trust

The sister of a man with Downs Syndrome has received an apology from the Belfast Trust following our investigation into his treatment in Belfast City Hospital.

NIPSO (NI Public Service… Health & Social Care May 2022

PSOW-202100024 — Wrexham County Borough Council

Mrs X complained that the Council failed to provide appropriate and adequate support to her sister, Ms Y, in the months leading to her death, including whether information was shared appropriately between the Council and a third-party organisation providing services on behalf of the Council (“the Provider”), and whether the …

PSOW (Public Services Om… Health Jul 2022

NIPSO-201916181 — Belfast Health and Social Care Trust

We investigated an incident in which a woman suffered a fractured vertebrae after a fall in hospital. We found that the Belfast Trust failed to prepare a proper falls assessment for the patient, and failed to fully investigate how the fall happened.

NIPSO (NI Public Service… Health & Social Care Jul 2022

23-017-219 — Birmingham City Council

Summary: Mrs X complained the Council refused to provide her son, Y, with school transport. Mrs X explained Y has additional needs, attends a special school and it was unsafe for him to walk to school. She said this caused Y and her distress because Y’s behaviours mean he is …

LGO (Local Government & … Education Upheld Jul 2024

NIPSO-17493 — Belfast Health and Social Care Trust

A Health Trust has apologised for the care and treatment given to a patient in the Emergency Department of the Royal Victoria Hospital, Belfast.

NIPSO (NI Public Service… Health & Social Care Oct 2019

PSOW-202302461 — Cardiff and Vale University Health Board

Ms A complained on behalf of her husband, Mr A, about the assessment and treatment provided by Cardiff and Vale Health Board (“the Health Board”) for a laceration to his left wrist when he attended the University Hospital of Wales (“the Hospital”) Emergency Department on 24 August 2022. The investigation …

PSOW (Public Services Om… Health Upheld Apr 2024

24-012-786 — London Borough of Lambeth

Summary: LGSCO finds the Council was at fault for failing to consider Ms X’s needs arising from her disability when replacing her shower. The Housing Ombudsman finds maladministration in the Council’s handling of Ms X’s reports of repairs. Both Ombudsmen find fault in the Council’s complaint handling. To remedy the …

LGO (Local Government & … Adult Care Services Upheld Jun 2025

24-016-501 — London Borough of Enfield

Summary: The Council failed to provide Miss X homelessness accommodation when it should have done and when it did house Miss X, the accommodation was unsuitable. This meant Miss X accrued debt she should not have and has remained in accommodation which does not meet her needs as a Disabled …

LGO (Local Government & … Housing Upheld Nov 2025

202503645 — Clackmannanshire and Stirling Health and Social Care Partnership

C, who has a progressive neurological disorder, complained that there was an unreasonable delay in the partnership providing adaptions to their home. We took independent advice from an occupational therapist (a healthcare professional who supports people to improve their ability to carry out everyday tasks). We found that this was …

SPSO (Scottish Public Se… Health and Social Care Not Upheld Feb 2026

NIPSO-18500 — Belfast Health and Social Care Trust

The Ombudsman has upheld elements of a complaint that appropriate steps were not taken to prevent an elderly patient from falling out of a hospital bed, but did not establish a link between her fall and her death the following day.

NIPSO (NI Public Service… Health & Social Care Jul 2020

PSOW-202100359 — Aneurin Bevan University Health Board

Mrs A complained about the care and treatment provided to her husband, Mr A, following a suspected stroke on 17 March 2019. In particular, she complained there was a delay in diagnosing diabetes, that record keeping had been poor, and that she felt the quality and timeliness of the Health …

PSOW (Public Services Om… Health Aug 2021

PSOW-202002273 — Betsi Cadwaladr University Health Board

During another investigation into concerns raised by Mr Y, the Ombudsman received evidence from the Health Board which indicated that, at the time Mr Y was placed on the urgent list for prostate cancer treatment in August 2019, there were a total of 16 other patients with the same urgent …

PSOW (Public Services Om… Health Aug 2021

PSOW-202005554 — Cwm Taf Morgannwg University Health Board

Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with asarcoma (a rare type of …

PSOW (Public Services Om… Health Upheld Jun 2022

PSOW-202107463 — Ceredigion County Council

Mr A complained on behalf of his son, Mr B, who lives in a residential home for adults with additional needs. The other residents of the house receive support from a Support Service (“the Support Service”) which is funded by the Council. Mr A complained that a staff member from …

PSOW (Public Services Om… Health Jul 2022

PSOW-202304865 — Hywel Dda University Health Board

Dr C complained about the care and treatment her late mother, Mrs A, received from Hywel Dda University Health Board on 28 and 29 December 2022 when she was an inpatient at Withybush Hospital (“the Hospital”). The following matters were investigated: a) Whether Mrs A’s pain relief was appropriate and …

PSOW (Public Services Om… Health Upheld Jun 2024

21-005-129 — Royal Borough of Greenwich

The Council refused to fund adaptations to a specialist bed. Consequently, Ms X does not have a bed that meets her needs.

LGO (Local Government & … Adult Care Services Upheld Mar 2022

21-017-229 — Birmingham City Council

Summary: We will not investigate Mr X’s complaint about the outcome of his occupational therapy assessment in relation to his request for major adaptations to his home. This is because there is no sign of fault by the Council in how it carried out and decided the assessment.

LGO (Local Government & … Adult Care Services Mar 2022

22-002-090b — Northumbria Healthcare NHS Foundation Trust (22 002 090b)

Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …

LGO (Local Government & … Health Upheld Dec 2022

201104061 — Scottish Prison Service

Mr C, who is a prisoner, injured his hand and was advised by a prison doctor that he would need to attend hospital. He was unhappy that he was not taken to hospital until the next day and he complained about this to the prison. The prison told him that …

SPSO (Scottish Public Se… Prisons Upheld Jul 2012

PSOW-202106137 — Isle of Anglesey County Council

Ms A complained that Direct Payments offered by the council were insufficient, that carer assessments were not in place and that adaptation work to her property had not been progressed because she was unable to appoint an agent. The council agreed to help Ms A identify and appoint an agent, …

PSOW (Public Services Om… Local Government Feb 2022

PSOW-202107102 — Betsi Cadwaladr University Health Board

Following receipt of the Health Board’s formal complaints response, Mr A had further questions about the standard of care and treatment provided to his late mother. He complained that the final complaints response erroneously referred to him by a different name. The Ombudsman was concerned that Mr A had outstanding …

PSOW (Public Services Om… Health Mar 2022

PSOW-202204393 — Flintshire County Council

Ms X complained about the Council’s handling of social services matters concerning her son, including direct payments, assessments, and plans. The assessment found that the independent investigation commissioned at stage 2 was thorough and competent. However, there were two issues identified which did not amount to best practice. The Council …

PSOW (Public Services Om… Local Government Feb 2023

PSOW-202405901 — Swansea Bay University Health Board

Mrs A complained that Swansea Bay University Health Board had failed to formally respond to her letters of complaint, in relation to her late grandmother’s care. The Ombudsman found that the Health Board had discussed Mrs A’s concerns with her in a meeting but it had failed to formally respond …

PSOW (Public Services Om… Health Nov 2024

20-007-956a — Black Country and West Birmingham Clinical Commissioning Group …

Summary: Miss X complained about problems with specialist equipment provided by the Council and NHS Clinical Commissioning Group. We have not upheld the complaint. We have now completed our investigation.

LGO (Local Government & … Health Not Upheld Feb 2022

20-007-956 — City of Wolverhampton Council

Summary: Miss X complained about problems with specialist equipment provided by the Council and NHS Clinical Commissioning Group. We have not upheld the complaint. We have now completed our investigation.

LGO (Local Government & … Adult Care Services Not Upheld Feb 2022

21-011-454 — Basingstoke & Deane Borough Council

Summary: Mrs X complains about the Council’s handling of her application for a disabled facilities grant. She says the Council produced an inadequate kitchen design which does not meet her needs. The Council was not at fault. It has designed a kitchen to meet Mrs X’s needs in line with …

LGO (Local Government & … Adult Care Services Not Upheld May 2022

24-001-044 — Devon County Council

Summary: We will not investigate this complaint about an unsuccessful application for a Blue Badge. This is because there is insufficient evidence of fault by the Council.

LGO (Local Government & … Adult Care Services May 2024

24-022-186 — Norwich City Council

We will not investigate Mr X’s complaint about how the Council have managed his Disabled Facilities Grant application. This is because there is not enough evidence of fault to justify an investigation.

LGO (Local Government & … Adult Care Services Jun 2025

24-010-015 — Northumberland County Council

Summary: Mr X complained the Council failed to properly assess his needs in relation to adapting his home under a Disabled Facilities Grant (DFG). The Council was not at fault.

LGO (Local Government & … Adult Care Services Not Upheld Jun 2025

PSOW-202202016 — Betsi Cadwaladr University Health Board

Ms P complained about care provided to her mother, Mrs Q, by the Health Board during her admission to the Emergency Department (“the ED”) at Ysbyty Glan Clwyd from November 30 2021. In particular, she complained that the Health Board failed to assess and transfer her mother to a ward …

PSOW (Public Services Om… Health Aug 2022