Inadequate Pre-Operative Risk Assessment
Insufficient pre-operative assessments and specialist reviews for patients with significant comorbidities, risking complications.
570 items
10 sources
3 inquiries
Source spread
Where this theme appears
Inadequate Pre-Operative Risk Assessment has been flagged across 10 independent accountability sources:
4 inquiry recs
146 PFD reports
7 committee recs
6 CQC actions
35 PPO recs
2 IOPC recs
1 IMB rec
1 patient safety alert
136 PHSO decisions
232 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (4)
IBI-7a(ii) — Tranexamic Acid - Scotland, Wales and NI
Recommendation: In Scotland, Wales and Northern Ireland offering the use of tranexamic acid should be considered a treatment of preference in respect of all eligible surgery.
Gov response: Scottish Government The Scottish Government’s Oversight and Assurance Group (OAG) Chair and Deputy Chair wrote to Health Boards in November 2024 asking them to review practice within their Board and confirm that they are offering …
Accepted
No update 2+ yrs
IBI-7a(i) — Transfusion Committees and Tranexamic Acid - England
Recommendation: In England, Hospital Transfusion Committees and transfusion practitioners take steps to ensure that consideration of tranexamic acid be on every hospital surgical checklist; that hospital medical directors be required to report to their boards and the chief executive of their …
Gov response: UK’s governments Recommendation 7 includes an especially complex set of sub recommendations. To ensure a joined up approach across the four nations, experts from across the four nations NHS bodies, blood services and external bodies …
Accepted in Part
No update 2+ yrs
4 — Reflection period for consent
Recommendation: We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. The GMC should monitor this as part of …
Gov response: Accepted in principle. GMC guidance on consent (updated 2020) already emphasises patients should have time to consider information before making decisions. The guidance states patients should not be placed under pressure to make decisions quickly. …
Accepted in Part
No update 2+ yrs
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
PFD Reports (146) — showing 50 strongest matches
Annie Jones
Concerns: An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, posing a significant risk of injury to vulnerable patients.
Response (Abbey Dale House): Abbey Dale House created an updated document providing a snapshot of each resident's needs, including a summary person handling plan, readily available to all staff. The care home adopted the …
Responded
Lucy Kilvert
Concerns: A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
Overdue
Jennifer Rushworth
Concerns: Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.
Overdue
Laura Hill
Concerns: Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Response (Stockport NHS Foundation Trust): Stockport NHS Foundation Trust has instigated an escalation process for locating equipment, to be monitored via the Datix system. The nurses involved were formally counselled, and the case was presented …
Responded
Herta Woods
Concerns: Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.
Overdue
Nathan Douthwaite
Concerns: A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns but states that NICE has the statutory function of producing clinical guidelines. NHS England will disseminate the case to NHS learning networks …
Overdue
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Overdue
Carol Walker
Concerns: Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.
Overdue
Betty Smith
Concerns: Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.
Overdue
Beryl Walters
Concerns: Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
Overdue
Patricia Mellor
Concerns: Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.
Overdue
Martin McCabe
Concerns: The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.
Overdue
Stephen Mayoll
Concerns: The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Response (Portsmouth Hospitals NHS Trust): Patients returning to the fracture clinic with lower limb injuries will have a reassessment of their VTE risk factors. A scanner has been ordered to digitally save and record reviews …
Responded
David Greenfield
Concerns: Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, hindering proper risk assessment.
Response (Priory Group): The Priory Group audited the competencies of medical staff in specialist wards and provided additional training where needed. They are ensuring a full baseline physical health assessment is in place …
Responded
Robert Stuart and Darren Hughes
Concerns: NHSBT could improve the core donor data form with more information and ensure all relevant information is transmitted to transplant centres; UHW Cardiff should ensure consultants view the EOS system and employ a team approach for organ acceptance, and a written account of the deaths should be shared with the transplant community.
Response (NHS Blood Transport): NHSBT has already taken action, including a review of the incident, sharing learning points with specialist nurses, hosting a working group to reduce recurrence risk in March 2015, and commencing …
Overdue
Neil Westerman
Concerns: Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, especially at night.
Response (Stockport NHS Trust): The Trust addressed the issue of a junior doctor performing the pre-operative assessment with the individual surgeon and discussed the case at a Morbidity & Mortality meeting. They reiterated the …
Responded
Nicola Tweedy
Concerns: Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. Discharge notes were also incomplete and checklists unfulfilled.
Response (Norfolk Norwich University Hospitals): The hospital implemented changes to prescribing practices based on an audit of day case patients, and produced an action plan prior to the inquest. An external inspection confirmed they had …
Response (Department of Health): The Department acknowledges the concerns and notes the Foundation Trust implemented an action plan. They highlight existing VTE risk assessment tools and data collection, and state NHS England will consider …
Responded
Ronald Smith
Concerns: There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
Overdue
Anthony Geerts
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response (Brighton and Sussex University Hospitals NHS Trust): Brighton and Sussex University Hospitals NHS Trust has integrated the neck of femur service at the Princess Royal Hospital. They also recruited a new Clinical Nurse Practice Educator and implemented …
Overdue
Patricia Holmes
Concerns: The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.
Response (East Kent University Hospitals NHS Trust): East Kent University Hospitals NHS Trust has an approved algorithm in place to assess and treat patients with trauma and bleeding risk. A governor's order was issued at HMP Wayland …
Responded
Karen O’Brien
Concerns: The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Overdue
Rachel Hollister
Concerns: The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.
Overdue
Casey Garrett
Concerns: Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.
Response (Health Education East of England): Health Education East of England describes actions planned by Bedford Hospital NHS Trust and the University of Bedfordshire to improve the learning environment for student midwives, including a student forum, …
Overdue
Mary James
Concerns: Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Overdue
Eileen Smith
Concerns: The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Response (Department of Health): The response acknowledges the concerns raised and references existing guidance and resources, including work by NHS England, NICE and the NPSA, but describes no specific actions taken or planned by …
Responded
Barry Pike
Concerns: The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.
Overdue
Sharon Henshall
Concerns: The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Overdue
Frederick Sutton
Concerns: Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.
Overdue
Rosalind Baird
Concerns: There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Overdue
Rosina Drury
Concerns: The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.
Overdue
Rebecca Jones
Concerns: Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.
Response (Department of Health): NHS England will spend £15m in 2016/17 to boost provision in areas that lack adequate health-based places of safety and is developing commissioning guidance for effective crisis response. HEE is …
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Darren Jones
Concerns: The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with the education of staff and availability of immunosuppressant drugs.
Overdue
Thelma Clarkson
Concerns: The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
Overdue
Stephen Adams
Concerns: Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.
Overdue
Bryan Catanach
Concerns: Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Overdue
Euphemia Aldred
Concerns: The report raises concerns that were not detailed in the excerpt.
Overdue
Ronald Bentley
Concerns: A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.
Response (BCIS): The British Cardiovascular Intervention Society (BCIS) circulated the report to its members via its official newsletter and passed on details to the British Heart Rhythm Society (BHRS).
Overdue
Marjorie Booth
Concerns: Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of missing a fracture outweighs radiation exposure risk for elderly patients.
Overdue
Lincoln Brady
Concerns: Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): The Trust has implemented presentation scanning for women in labour, with a training and skills maintenance programme for midwives. The partogram will include a section for documenting scan results, and …
Responded
David Aughton
Concerns: The concerns text for this report is incomplete, so specific issues cannot be identified.
Overdue
Karen Ravenscroft
Concerns: The concerns text for this report is incomplete, so specific issues cannot be identified.
Overdue
Rhianne Barton
Concerns: Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National guidelines on bariatric surgery in pregnancy are also lacking.
Response (Ashford and St Peters Hospital NHS Trust): The Trust has changed Consultant working practices to facilitate timely review of patients, produced a guideline for the management of pregnant women who have undergone bariatric surgery, raised awareness of …
Overdue
Kirsty Childs
Concerns: At the inquest, it was not possible to trace an appropriate individual from the now defunct NHS direct organisation to give evidence although an internal enquiry report which had been undertaken prior to.
Overdue
Joshua Knox-Hooke
Concerns: The patient was not kept within eyesight at all times as required by Trust policy, and it is common for patients to leave A&E prior to psychiatric assessment; the triage nurse was unaware of nurses' holding power under the Mental Health Act.
Responded
Jean Stockley
Concerns: Despite a deteriorating respiratory condition and a rising NEWS score, a junior doctor did not review the patient, and it was unclear whether the appropriate doctor had been contacted; the coroner suggested a potential training need.
Responded
Michael Blow
Concerns: An INR test was not carried out, and warfarin was restarted based on an outdated INR reading, without considering the impact of other treatments; the coroner noted a need to clarify the relevant protocol for junior doctors and nurse practitioners.
Overdue
Harry Glibbery
Concerns: The doctor did not prescribe Clexane in accordance with Derriford Protocol, this was not identified during Pharmacy reviews, and there were difficulties weighing patients whose medication is weight-dependent.
Responded
Diana Ritchie
Concerns: Mrs Ritchie was recovering from major surgery and on her second day post operatively was suspected of having an Ileus.
Responded
George Watson
Concerns: Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.
Overdue
Committee Recommendations (7)
#7 —
Recommendation: Early in the pandemic, the National Institute for Health and Care Excellence’s (NICE) critical care guidelines and doctors’ inappropriate or blanket use of “Do not attempt resuscitation” (DNAR) notices were potentially discriminatory. While we welcome actions taken swiftly to address …
Gov response: Recommendation 7 and 8 The Committee says it is very important that the Government gives much more money to all social care areas to make sure services are much more person- centred and meeting people’s …
Under Consideration
#18 — Ensure leasehold extension legislation applies equally to all shared ownership properties and leaseholders.
Recommendation: Finally, the Government should ensure that any legislation passing through Parliament which has provisions to reduce the cost of, and simplify, the process of leasehold Shared Ownership 41 extension (for example, as in the Leasehold and Freehold Reform Bill) also …
Gov response: 42. The Government agrees with the Committee that, wherever possible, shared owners should enjoy the same rights as other leaseholders. This is reflected in our approach to the Leasehold and Freehold Reform Bill, with shared …
Accepted
#17 — Update Homes England Capital Funding Guide to require specialist advice teams for shared owners.
Recommendation: We urge Homes England to update its Capital Funding Guide for shared ownership to specify that providers should only be selling shared ownership properties on the condition they set up and maintain specialist teams of professionals who can provide accurate, …
Gov response: 33. The Government agrees with the Committee on the importance of specialist advice throughout all stages of the shared ownership journey, and a significant amount of work has been undertaken, and is ongoing, to ensure …
Not Accepted
#16 — Ensure appropriate advice is readily available for shared owners making significant financial decisions.
Recommendation: It is unacceptable that shared owners are having to make significant financial decisions without appropriate advice being readily available, and we believe the Government must act to remedy this. We also believe that it is unacceptable that shared owners do …
Gov response: 33. The Government agrees with the Committee on the importance of specialist advice throughout all stages of the shared ownership journey, and a significant amount of work has been undertaken, and is ongoing, to ensure …
Not Addressed
#15 — Mandate Homes England ensure providers include lease guidance and signposting in Key Information Documents.
Recommendation: Homes England should ensure that providers include simple guidance on lease arrangements within the Key Information Documents distributed to shared owners, including information on how rights and responsibilities are allocated and guidance on how to extend the lease. It should …
Gov response: 31. All of Homes England’s key information documents contain relevant information on shared ownership leases, including the rights and responsibilities of the shared owner and their registered provider, as well as the lease extension process …
Accepted
#14 — Shared owners lack access to advice on leasehold tenure and lease extension complexities.
Recommendation: It is clear that many shared owners lack access to advice and guidance which can explain to them clearly and impartially the complexities of leasehold tenure and their rights and responsibilities under their shared ownership lease, as well as advise …
Gov response: 31. All of Homes England’s key information documents contain relevant information on shared ownership leases, including the rights and responsibilities of the shared owner and their registered provider, as well as the lease extension process …
Accepted
#29 — Suspend notices of intent for Rwanda removals and review initial screening procedures thoroughly.
Recommendation: We are deeply concerned that the Home Office’s case-by-case risk assessments prior to issuing notices of intent to remove potentially inadmissible asylum claimants to Rwanda appear to be inadequate. There is evidence that a significant number of vulnerable people, to …
Gov response: In relation to the recommendation at paragraph 184, people should claim asylum in the first safe country they reach, those coming by small boats to the UK have left a safe country with a similar …
Accepted
CQC Inspection Actions (6)
BMI Southend Private Hospital
The provider must ensure that the need for VTE screening is assessed by the service and administered to patients as per the service’s policy in line with national best practice.
Must Do
BMI Southend Private Hospital
The provider must ensure that risks to patients are identified through surgical pre-assessment prior to surgery being undertaking under local anaesthetic.
Must Do
Meet The Baby
The provider should ensure that appropriate further consent procedures are in place before transvaginal scans are introduced as a service.
Should Do
Hazelwood
We recommend the provider takes advice from two people's GPs to determine if they are of suitable weight for their height and to assess whether specialist nutritional advice is required.
Should Do
Meet The Baby
The provider should consider asking women whether they have a latex allergy before they attend for a scan in order that appropriate measures can be taken to prevent them from coming into contact with latex in the clinic.
Should Do
Margaret Clitherow House
The registered person is recommended to take advice from a suitably qualified person and follow best practice in relation to the monitoring of risks associated with people's intake of fluids.
Should Do
PPO Death in Custody Recommendations (35)
The Operational Security Group Director for HMPPS
The Operational Security Group Director for HMPPS should monitor, over the next three months, how many prisoners at HMP Highpoint are escorted to hospital without restraints (for inpatient admissions and outpatient appointments) and report back to the Ombudsman.
The Governor and Head of Healthcare (HMP Highpoint)
The Governor 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 information …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare and security teams share appropriate information and work collaboratively to complete escort risk assessments, to ensure restraints decisions are appropriate.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare input into escort risk assessments is based on up-to-date medical information and is clear and sufficiently detailed.
The Governor
The Governor should ensure that prison staff understand that medical information about a prisoner must be sought and properly considered when deciding whether to use restraints and in cases where a medical objection is disregarded or is not obtained the …
The Director and Head of Healthcare
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, that healthcare staff complete the medical information section of the escort risk …
The Governor
The Governor should ensure that authorising managers understand the legal position on the use of restraints and that assessments fully take into account the health of a prisoner and are based on the actual risk the prisoner presents at the …
The Director and Head of Healthcare
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, that healthcare staff complete the medical information section of the escort risk …
The Head of Healthcare
The Head of Healthcare should review the systems and processes for training and supporting staff to complete escort risk assessments for patients requiring emergency hospital admission.
The Governor of HMP Swaleside
The Governor should ensure that all staff completing escort risk assessments for prisoners taken to hospital involve healthcare input and authorisation by a Governor or nominated equivalent, in line with the External Escorts Policy Framework 2022.
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: staff are using the current escort risk assessment template, as outlined in the policy framework.
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: all staff involved in the escort risk assessment process receive training on the Graham judgment and have a clear understanding of how it …
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: healthcare staff are routinely involved in the escort risk assessment process, taking a prisoner’s current medical condition into consideration, including how this impacts …
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: in line with policy, a thorough escort risk assessment is completed for every non-life-threatening emergency hospital escort;
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking and reviewing risk assessments for prisoners taken to and admitted to hospital understand the legal position, that assessments fully take into account prisoners’ health and are based on …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners who are attending hospital appointments: • complete the risk assessment documents in full, clearly setting out their rationale for the decisions; and • understand …
The Head of Healthcare
The Head of Healthcare should ensure that a full set of clinical observations are taken during reception screening in accordance with NICE guidance and any anomalies escalated to a senior clinician.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff completing and authorising risk assessments justifying the use of restraints on prisoners taken to hospital understand the legal position, and that assessments fully take into account the health of …
The Director
all staff undertaking risk assessments for prisoners attending hospital understand the legal position on the use of restraints, including that their assessments fully take into account the prisoner’s health and mobility, and are based on the actual risk the prisoner …
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that escort risk assessments fully take into account the health of a prisoner and are based on the actual risk he presents at the time.
The Governor
The Governor should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into account when assessing a …
The Operational Manager
The Operational Manager should ensure that prisoners in segregation are managed in line with PSO 1700, in particular: • Prisoners on an ACCT are segregated only in exceptional circumstances. • Where a segregated prisoner becomes subject to ACCT procedures, a …
The Governor and the Head of Healthcare
The Governor and the 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 …
The Governor
The Governor should ensure that the medical sections of risk assessments are fully completed, and in circumstances where this is genuinely not possible, the authorising officer should indicate why, and when restraint levels will be reassessed.
The Director General of Prisons
The Director General of Prisons should issue national guidance on risk assessments for clinically high-risk prisoners, to ensure that protective measures are fully considered for those employed as cleaners, or in other roles which significantly increase the possibility of exposure …
The Governor
The Governor should review whether the quality assurance process for escort risk assessments is sufficiently robust and consider introducing SLT review of a random sample to identify any ongoing issues.
The Head of Healthcare at Isle of Wight
The Head of Healthcare at Isle of Wight should ensure that staff consider using clinical hold where a prisoner is awaiting surgery for a life-threatening condition and record this in the medical records.
The Governor of HMP Hull
escort staff should question the escort risk assessment and review previous assessments if there are clear indications that restraints should not be used;
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff accurately reflect their professional opinion on restraint risk assessment forms, that there are clear and considered conversations between healthcare and prison staff about a prisoner’s risk where necessary and that …
The Governor and Head of Healthcare
The Governor 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: • healthcare staff complete the healthcare section of the escort …
The Governor
The Governor should ensure that all staff undertaking and reviewing risk assessments for prisoners admitted to hospital understand the legal position on the use of restraints, that assessments fully take into account the prisoner’s health and mobility and are based …
The Director and Head of Healthcare
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 information …
The Governor and Head of Healthcare
The Governor 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.
The Governor of HMP Wormwood Scrubs
The Governor should review Wormwood Scrubs’ policy on escort risk assessments for emergency hospital journeys to ensure that staff take account of a prisoner’s presenting medical condition, as well as public protection factors, when considering the level of restraints.
The Head of Healthcare
ensuring requests for clinical investigations, such as requests for chest X-rays, are actioned promptly
IOPC Learning Recommendations (2)
Recommendation - Metropolitan Police Service, November 2020
The IOPC recommends the Metropolitan Police Service reviews and amends their stop and search policies, procedures and training to include a routine risk assessment of the physical environment in which the individual has been stopped, and that this is considered …
Recommendation - Bedfordshire Police, November 2020
The IOPC recommends that Bedfordshire Police should review and amend their policy and guidance regarding the transportation of vulnerable individuals with single crewed officers. The same policy, guidance, risk assessments and safeguarding considerations for those arrested or formally detained should …
National Patient Safety Alerts (1)
PHSO Casework Decisions (136)
P-003007 — Lewisham and Greenwich NHS Trust
Mrs R complains the Trust delayed diagnosing her hip dislocation for three days because it did not take an X-ray following hip replacement surgery. She also complains the Trust did not consider her needs or obtain informed consent for surgery.
NHS in England
Upheld
Sep 2024
P-001638 — Manchester University NHS Foundation Trust
Mr R complains that the Trust should not have performed an angiogram on his father as he died from a cardiac arrest later that day.
NHS in England
Partly Upheld
Sep 2022
P-001846 — Newmedica
Mr Y complains about his care and treatment after a left eye cataract removal. He says Newmedica did not seal his eye correctly and this resulted in fluid escaping and infection.
NHS in England
Dec 2022
P-001751 — Royal United Hospitals Bath NHS Foundation Trust
Mr D complains the Trust did not give him appropriate information about the risks of a colonoscopy and a polypectomy before he had the procedures in April 2019.
NHS in England
Partly Upheld
Jan 2023
P-001753 — King's College Hospital NHS Foundation Trust
Mr E complains the Trust did not take a urine test before his cystoscopy procedure in August 2020.
NHS in England
Partly Upheld
Jan 2023
P-002558 — A practice in the Teignbridge area
Mr I complains the Practice took a functional approach to his rib pain and did not arrange appropriate investigations.
NHS in England
Apr 2024
P-002638 — East Kent Hospitals University NHS Foundation Trust
Miss R complains her father died because the Trust gave him food and drink when he could not swallow after a stroke. She also complains he should have been isolated in a side room to protect him from COVID-19.
NHS in England
Partly Upheld
May 2024
P-003037 — The Princess Alexandra Hospital NHS Trust
Mrs A complains the Trust ignored her concerns about the cannula not being properly in place, causing the contrast dye (a chemical used to make scan imaging clearer) to leak into her left hand. She also says it did not provide her with appropriate information about her injury after the …
NHS in England
Oct 2024
P-003054 — County Durham and Darlington NHS Foundation Trust
Mr K complains that in May 2022 the Trust did not do an ultrasound scan on his wife and that it gave her anticoagulant medication without checking if she had any internal bleeding.
NHS in England
Oct 2024
P-003090 — University Hospitals of North Midlands NHS Trust
Mrs M complains the Trust did not correctly treat her mother's chest pains before she had a cardiac arrest.
NHS in England
Upheld
Oct 2024
P-004325 — University Hospitals Birmingham NHS Foundation Trust
Mrs E complains the Trust did not treat her pregnancy-induced hypertension during the antenatal period, and did not appropriately monitor her whilst in hospital prior to her planned induction. She also complains the Trust did not administer her epilepsy medication whilst in hospital, and that the Trust performed a sterilisation …
NHS in England
Upheld
Nov 2025
P-004367 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs D complains whilst she was giving birth, the obstetrician continued despite struggling to use forceps, then failed to properly stitch her episiotomy or check for placental remains. She complains once her daughter was born, she was left unattended in a neonatal cot and her facial wound was not cleaned …
NHS in England
Nov 2025
P-004407 — Shrewsbury and Telford Hospital NHS Trust
Miss X complains about the care and treatment she received by the Trust. She says she was not given any prenatal care until 21 weeks. She also says the Trust left her alone to give birth and she was given incorrect information by a doctor.
NHS in England
Nov 2025
P-004421 — St George's University Hospitals NHS Foundation Trust
Mr F is understandably concerned that St George’s University Hospitals NHS Trust did not discuss the risks of the penile straightening surgery he had in early January 2023.
NHS in England
Partly Upheld
Dec 2025
P-004692 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mrs Y complains about the care and treatment provided to her mother by the Trust. She says the Trust did not consent her mother correctly for surgery and failed to provide timely reassurance when her mother experienced distressing symptoms post-surgery.
NHS in England
Partly Upheld
Jan 2026
P-001097 — University Hospitals Sussex NHS Foundation Trust
Mrs U complains sedation was not used as planned for a joint injection procedure and she was not given the opportunity to cancel the procedure to come back another day when sedation would be available.
NHS in England
Partly Upheld
Aug 2021
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-001271 — A hospital in the Essex area
Mrs R complains that following a hip replacement operation, she is still experiencing pain, is unable to walk without resting, and needs to take painkillers. She told us she has been left unable to participate in everyday activities and hobbies.
NHS in England
Jan 2022
P-001276 — East Suffolk and North Essex NHS Foundation Trust
Mrs T complained about the care and treatment she received from the A&E department at the Trust when she attended after a fall on 2 November 2019. She specifically complained that she was not referred for an X-ray, and did not receive appropriate care or follow-up care.
NHS in England
Upheld
Jan 2022
P-001341 — Leeds Teaching Hospitals NHS Trust
Mrs E complains about the care and treatment she received for her spinal cord stimulator battery replacement surgery at a private hospital in Leeds, and the Leeds Teaching Hospitals NHS Trust.
NHS in England
Partly Upheld
Mar 2022
P-001511 — A healthcare provider in the Nottingham area
Mr D complains that the healthcare provider did not promptly arrange an urgent dermatology appointment for him and prescribed him medication without physically examining him first in December 2018.
NHS in England
Partly Upheld
Jul 2022
P-001587 — Stockport NHS Foundation Trust
Mrs A complains that the Trust did not complete her kidney stent replacement surgery correctly.
NHS in England
Aug 2022
P-001686 — Surrey and Sussex Healthcare NHS Trust
Mr O complains the Trust did not properly assess his late wife and did not do a back scan in November 2020.
NHS in England
Oct 2022
P-001766 — Leeds Teaching Hospitals NHS Trust
Ms P complains the Trust missed opportunities during antenatal scans to identify that her son had a heart condition.
NHS in England
Jan 2023
P-001735 — Guy's and St Thomas' NHS Foundation Trust
Ms R complains the Trust failed to consider her family history when assessing her risk of breast cancer and did not give her a gene mutation test.
NHS in England
Jan 2023
P-001874 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs B complains she did not consent to a junior doctor administering spinal anaesthesia. She says the junior doctor had not done this procedure before and she thinks something went wrong causing her to experience ongoing non-epileptic seizures. Mrs B also says a ward nurse tried to bring her out …
NHS in England
Mar 2023
P-001906 — Moorfields Eye Hospital NHS Foundation Trust
Miss W complains the Trust did not tell her about the risks of her cataract operation, it made a mistake during the procedure, and it did not report this after the procedure.
NHS in England
Mar 2023
P-003282 — Somerset NHS Foundation Trust
Mrs L complained the Trust did not use a consent procedure before her breast biopsy. She complained something went wrong with the procedure and the Trust did not tell her there had been a complication. She also complains the Trust did not give her enough aftercare and she still has …
NHS in England
Partly Upheld
Apr 2023
P-001980 — University Hospitals of Derby and Burton NHS Foundation …
Mr A complains the Trust burned his back during a jaw operation in December 2020. He also complains it did not give him appropriate aftercare.
NHS in England
May 2023
P-002012 — Birmingham Women's and Children's NHS Foundation Trust
Mrs I complains the Trust did not assess and treat her properly before diagnosing cancer. She also says it did not drain an ovarian cyst before her operation and the cyst ruptured during surgery.
NHS in England
Jun 2023
P-002106 — Circle Health Group
Mr N complains the Group failed to properly prepare for the removal of a 15cm lipoma from his shoulder, in the months leading up to surgery on 20 April 2022.
NHS in England
Jul 2023
P-003886 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs X complains that during a hysteroscopy in December 2020, the Trust failed to give her appropriate pain relief or to stop the procedure when it became too painful.
NHS in England
Jul 2023
P-003893 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs F complains about the Trust's care of her brother in May and June 2019. She says it did not properly explain the risks of getting deep vein thrombosis (DVT) after lower leg surgery, or of how to recognise the symptoms, staff did not properly assess or treat his symptoms, …
NHS in England
Upheld
Oct 2023
P-002282 — University Hospitals of North Midlands NHS Trust
Mr U complains about the care and treatment he had from the Trust after his quadruple bypass surgery. He complains he woke up from surgery and asked a junior nurse for a glass of water but, instead, a nurse turned him on his side causing a major bleed for which …
NHS in England
Nov 2023
P-002393 — Imperial College Healthcare NHS Trust
Miss L complains that the Trust completed both her eye operations without anaesthetic, tore her retina during one of the operations, left silicon oil in her eye after the first operation and failed to communicate the possible outcomes of surgery.
NHS in England
Jan 2024
P-002473 — University Hospitals of Derby and Burton NHS Foundation …
Mrs H complains the Trust did not treat a urinary tract infection properly and did a procedure although she had an infection. She also complains about her experience on the delivery ward.
NHS in England
Feb 2024
P-002483 — University Hospitals Birmingham NHS Foundation Trust
Mrs O complains the Trust did not take care with her husband's oxygen mask and it did not think about his health problems when deciding on treatment.
NHS in England
Feb 2024
P-002441 — Frimley Health NHS Foundation Trust
Ms D complains Buckinghamshire Healthcare NHS Trust should not have prescribed her father Diamox. She complains Frimley Health NHS Foundation Trust did not properly investigate or treat his symptoms or provide good hydration and nutrition.
NHS in England
Partly Upheld
Feb 2024
P-003311 — County Durham and Darlington NHS Foundation Trust
Mrs E complains her surgeon did not warn her she might experience a permanent loss of sensation after having a hysterectomy.
NHS in England
Partly Upheld
Feb 2024
P-003286 — East Sussex Healthcare NHS Trust
Miss H complains about the Trust’s care and treatment between 2012 and 2021. She complains the Trust failed to tell her about the long-term complications of the endometrial ablation procedure (treatment for heavy periods).
NHS in England
Partly Upheld
Mar 2024
P-002518 — A practice in the Oxfordshire area
Mrs U says that between January and April 2022 the Practice did not correctly assess or complete medical tests on her mother, Mrs A, before she was admitted to hospital where she died from cancer.
NHS in England
Mar 2024
P-002541 — Royal Devon University Healthcare NHS Foundation Trust
Ms V complains the Trust did not properly assess her in A&E and did not provide follow-up or safety netting advice before sending her home.
NHS in England
Upheld
Apr 2024
P-002777 — Countess of Chester Hospital NHS Foundation Trust
Miss EB complains on behalf of her mother that when she attended the Trust in March 2021, staff performed a bladder investigation when she had a severe thrush infection.
NHS in England
Jul 2024
P-002809 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss B complains about the care and treatment the Trust gave to her mother during two hospital admissions. Miss B complains about the management of pressure ulcers, lack of MRI scan and end of life care.
NHS in England
Jul 2024
P-002948 — Surrey and Sussex Healthcare NHS Trust
Miss U complains about the care the Trust gave to her cousin. She says it did an inappropriate assessment, it did not provide an appropriate treatment plan for pneumonia and it wrongly discharged her with oral antibiotics.
NHS in England
Partly Upheld
Sep 2024
P-003083 — George Eliot Hospital NHS Trust
Miss Y complains about failings checking her partner’s preoperative samples and in his later Emergency Department discharge. She also complains about communication and nursing care failings in his later hospital admission, and not being able to visit him.
NHS in England
Oct 2024
P-003167 — A practice in the Bradford area
Mrs O complains the Practice's care and treatment in October 2023 when she attended for a steroid injection in her wrist for carpal tunnel syndrome.
NHS in England
Nov 2024
P-003221 — University Hospital Southampton NHS Foundation Trust
Mrs F complained the Trust did not manage her father’s warfarin safely and took too long to arrange a CT scan.
NHS in England
Not Upheld
Dec 2024
P-003202 — Blackpool Teaching Hospitals NHS Foundation Trust
Mr R complains that the Blackpool Teaching Hospitals NHS Foundation Trust gave his mother incorrect doses of medication used for anaesthesia and procedural sedation from 11 August to 24 August 2021. He also complains the Trust did not discuss the Do Not Attempt Resuscitation Order decision before putting this in …
NHS in England
Not Upheld
Dec 2024
P-003353 — Nottingham University Hospitals NHS Trust
Mr L complains Nottingham University Hospitals NHS Trust gave his father chemotherapy without assessing if he was well enough for this and he says this caused his father to deteriorate and die sooner than he should have.
NHS in England
Partly Upheld
Feb 2025
LGO / SPSO Decisions (232)
NIPSO-19483 — Northern Health and Social Care Trust
We partially upheld a complaint that a patient contracted sepsis because he was released too early from Antrim Area Hospital. We asked the hospital to apologise for its failings, and to review its procedures on discharge of patients from the ward in question.
NIPSO (NI Public Service…
Health & Social Care
Aug 2021
NIPSO-202003412 — Western Health and Social Care Trust
We upheld a complaint from a woman who said she did not give her consent to a surgical procedure. We also found the Trust did not follow the right procedure when it decided the case did not meet the threshold for a Serious Adverse Incident investigation.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Aug 2024
NIPSO-202006867 — Northern Health and Social Care Trust
The Northern Trust should not have left it to the day of the surgery to explain to a patient the potential complications. The patient said that if she had known the possible consequences she would not have given her consent.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Aug 2025
NIPSO-18545 — Northern Health and Social Care Trust
The care and treatment provided to a complainant by the Accident & Emergency Department at Causeway Hospital was 'in accordance with good medical practice.'
NIPSO (NI Public Service…
Health & Social Care
Jul 2000
NIPSO-202000196 — Western Health and Social Care Trust
We asked the Western Health Trust to reflect on what it might have done differently in the treatment of an elderly patient in Altnagelvin Hospital.
NIPSO (NI Public Service…
Health & Social Care
Aug 2022
PSOW-202106222 — Betsi Cadwaladr University Health Board
Mrs A complained about her nursing care during an admission to Ysbyty Glan Clwyd after fracturing her spine in a fall. Mrs A said that the Health Board failed to maintain spinal precautions (“SPs” – to stop movement of the spine to prevent injury to the spinal cord) causing her …
PSOW (Public Services Om…
Health
Sep 2022
PSOW-202306571 — Powys Teaching Health Board
Ms X complained about the standard of care provided to her father, Mr Y, when he was an inpatient at Bronllys Hospital, which is a GP-led hospital service. Specifically, Ms X complained that doctors should have diagnosed Mr Y’s heart failure sooner and arranged an earlier transfer to a different …
PSOW (Public Services Om…
Health
Not Upheld
May 2024
PSOW-202401586 — Swansea Bay University Health Board
Mr C complained about care provided to his mother, Mrs D, by Swansea Bay University Health Board in May 2023. Specifically, he was concerned that a consultant psychiatrist had noticed that his mother had suffered a Transient Ischaemic Attack (“TIA” – also known as “mini strokes”, they are caused by …
PSOW (Public Services Om…
Health
Sep 2024
PSOW-202408596 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint raised in February 2024. The Ombudsman found that the Health Board had failed to respond to Mrs X’s complaint. The Ombudsman stated that this caused uncertainty and frustration for Mrs X. The Ombudsman decided to …
PSOW (Public Services Om…
Health
Apr 2025
PSOW-202408733 — Aneurin Bevan University Health Board
Mrs A complained that Aneurin Bevan University Health Board had failed to address her concerns raised in August 2024 and had failed to complete a second investigation into the sad death of her son. The Ombudsman obtained further information from the Health Board and decided that although Mrs A was …
PSOW (Public Services Om…
Health
Apr 2025
NIPSO-202000460 — Belfast Health and Social Care Trust
A patient was in pain for longer than necessary because of delays by the Belfast Trust to obtain the results of a private MRI scan.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Feb 2023
NIPSO-201916274 — GP
We investigated whether an increase in a man’s prescription caused him to attend hospital the following day. We found the Practice’s increase in the dose fell within the prescribed limits.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Mar 2024
NIPSO-202401489 — Northern Health and Social Care Trust
We upheld a complaint from a patient who claimed that the delay in her surgery left her with a permanent disability. We also found that the Trust failed to communicate with her about her care and treatment.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2026
PSOW-202103038 — Betsi Cadwaladr University Health Board
Mrs X complained that the Health Board had not provided her with a response to her complaint relating to the loss of her son’s blood samples. He had been undergoing investigations and she had received no explanation as to how the samples had been lost. The Ombudsman decided that the …
PSOW (Public Services Om…
Health
Aug 2021
PSOW-202002703 — Betsi Cadwaladr University Health Board
Mr Y complained that the Health Board: (a) Failed to report on an X-ray taken at his wife’s (Mrs Y) attendance at Glan Clwyd Hospital Emergency Department (“ED”) on 26 October 2019. He said this delayed appropriate medical management resulting in a further ED admission on 4 November. Had Mrs …
PSOW (Public Services Om…
Health
Upheld
Aug 2021
PSOW-202100242 — Aneurin Bevan University Health Board
Ms B and Mr C complained that Aneurin Bevan University Health Board (“the Health Board”)failed to provide appropriate care and treatment during Ms B’s pregnancy and labour which resulted in the loss of their son, E. In particular, Ms B and Mr C complained that the Health Board failed to …
PSOW (Public Services Om…
Health
Upheld
Dec 2021
PSOW-201900726 — Betsi Cadwaladr University Health Board
Mr X’s complaint to the Ombudsman was in relation to a number of matters concerning his late mother, Mrs Y. Mrs Y’s care and complaint handling Mr X complained about aspects of his late mother, Mrs Y’s, care while she was an inpatient at the Hergest Unit between July and …
PSOW (Public Services Om…
Health
Dec 2021
PSOW-202106700 — Cwm Taf Morgannwg University Health Board
Mrs A complained about the care and treatment provided to her late husband by the Health Board. The Ombudsman found that, following its initial complaint response, the Health Board held a meeting with Mrs A in December 2021 and had agreed to further investigate her concerns. The Health Board made …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202006430 — Betsi Cadwaladr University Health Board
Mr X’s GP referred him to Ysbyty Glan Clwyd on 29 November 2019 and 26 February 2020 on an urgent basis with pilonidal sinus symptoms. Mr X attended the Hospital’s ED on 22 June, a MRI scan was requested, but Mr X left before he was discharged. Mr X attended …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2022
PSOW-202004139 — Hywel Dda University Health Board
Mr A complained about the treatment that he had received from Hywel Dda University Health Board. He said that the Health Board had failed to diagnose an avulsion (pulling or tearing away) injury to a tendon (strong tissue that connects a muscle to a bone) in his left ring finger …
PSOW (Public Services Om…
Health
Upheld
Mar 2022
PSOW-202004499 — Aneurin Bevan University Health Board
Mr D complained that the care and treatment that his late mother in law, Mrs M, received following her transfer from the Royal Gwent Hospital (“the First Hospital”) to Ystrad Fawr Community Hospital (“the Second Hospital”) contributed to her sudden death some 2 days later from Hospital Acquired Pneumonia (“HAP”). …
PSOW (Public Services Om…
Health
Upheld
Mar 2022
PSOW-202000167 — Aneurin Bevan University Health Board
Mr L complained about the care provided to his late mother, Mrs M, when she was an inpatient in November 2019. Specifically, Mr L complained that the Health Board failed to monitor and treat Mrs M’s breathlessness properly; failed to provide her with adequate support to use the toilet; did …
PSOW (Public Services Om…
Health
Upheld
Mar 2022
PSOW-202005555 — Swansea Bay 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 a sarcoma (a rare type …
PSOW (Public Services Om…
Health
Upheld
Jun 2022
PSOW-202103161 — Hywel Dda University Health Board
Mrs G complained about the care and treatment provided to her late husband Mr G, by Hywel Dda University Health Board between September 2019 and March 2020 following a shoulder operation. Mrs G was concerned that: a) The Health Board failed to adequately investigate and treat Mr G’s ongoing shoulder …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202105722 — Betsi Cadwaladr University Health Board
Mrs Y complained about her mother, Mrs A’s, care, and treatment by the Health Board during Mrs A’s admission to Wrexham Maelor Hospital between 22 July and 4 August 2020. She complained that the Health Board transferred Mrs A to a COVID 19 designated ward for treatment and treated Mrs …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202301555 — Hywel Dda University Health Board
Mr G complained about the care provided to his father, Mr M. Mr G said that Hywel Dda University Health Board (“the Health Board”) failed to diagnose Mr M’s lung cancer promptly, and that it discharged Mr M inappropriately and without palliative support in November 2021. The Ombudsman found that …
PSOW (Public Services Om…
Health
Not Upheld
Jan 2024
PSOW-202208381 — Hywel Dda University Health Board
Mrs A complained about the care and treatment Hywel Dda University Health Board provided to her late husband, Mr A. Specifically she complained that the Health Board failed to identify an abdominal aortic aneurysm on a scan that her late husband underwent, and that this failure meant that he failed …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202207425 — Swansea Bay University Health Board
Mrs Z complained about the care and treatment that she had received from Swansea Bay University Health Board. The investigation considered whether there was a failure to assess Mrs Z’s injury properly when she attended hospital, which led to a failure to diagnose a hamstring tear, and if this led …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202203822 — Hywel Dda University Health Board
Mrs A complained about the care and treatment provided to her husband, Mr A, by Hywel Dda University Health Board (“the Health Board”), following his attendance to Glangwilli General Hospital (“the Hospital”) in August 2021. Specifically, she queried whether the treatment he received for gallstones reached a reasonable standard. She …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202203786 — Cardiff and Vale University Health Board
Mrs A’s complaint related to the care and treatment that she received from Cardiff and Vale University Health Board (“the Health Board”). Specifically, Mrs A complained that the Health Board had failed to diagnose her with a vesico-vaginal fistula (an abnormal opening between the bladder and vagina) in a timely …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202203509 — Swansea Bay University Health Board
The investigation found that Mrs A was not fully aware of how unwell her husband was, and the paramedics and clinicians ought to have known this and further consideration should have been given to involving Mrs A in her husband’s care. Mrs A was not informed about the do not …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202203229 — Betsi Cadwaladr University Health Board
The Ombudsman investigated Mr A’s complaint about the care he received in September 2021 after he presented at an Emergency Department (“ED”) with a severe headache. The investigation considered whether the following were clinically appropriate: • the diagnosis, which resulted in a lumbar puncture (a thin needle inserted into the …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202202959 — Swansea Bay University Health Board
Mr A complained about the care and treatment provided by Swansea Bay University Health Board (“the Health Board”) after he accidentally cut his left index finger with a utility knife. In particular, he said that the Health Board failed to prescribe appropriate antibiotics to prevent an infection at the time …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202201990 — Cardiff and Vale University Health Board
Ms C complained about whether the treatment she received at the University Hospital Llandough on 6 July 2021 was appropriate. Ms C said that she had been given an incorrect diagnosis and prognosis which led her to close her business and suffer much mental anguish. The investigation found that the …
PSOW (Public Services Om…
Health
Not Upheld
Jan 2024
PSOW-202201816 — Cwm Taf Morgannwg University Health Board
Ms C complained about the care and treatment her late father, Mr A, received when he was admitted to hospital on 2 occasions between 10 December 2021 and 14 January 2022. We considered whether communication with Mr A’s family, including around visiting restrictions, during his time in hospital, was sufficient …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202104268 — Cardiff and Vale University Health Board
Mrs A complained that there was an unreasonable delay by the Health Board in securing appropriate clinical treatment for her daughter, B, between March 2021 – when she first attended University Hospital of Wales with a jaw dislocation – and October 2021 when she was referred to a specialist hospital …
PSOW (Public Services Om…
Health
Upheld
Feb 2024
PSOW-202108316 — Hywel Dda University Health Board
Miss A complained about the care provided to her father, Mr B, by the Health Board between January and July 2020. The investigation considered whether the Health Board failed to diagnose Mr B’s cauda equina syndrome (“CES” – a rare and severe type of spinal stenosis – where the bundle …
PSOW (Public Services Om…
Health
Upheld
Feb 2024
PSOW-202300527 — Betsi Cadwaladr University Health Board
Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital (“the Hospital”) in July 2022 . Ms A had several medical conditions, including epilepsy (a condition which causes seizures), cerebral palsy (a condition that affects movement and co-ordination) and learning disabilities. She lived …
PSOW (Public Services Om…
Health
Jun 2024
PSOW-202304528 — Cardiff and Vale University Health Board
The Ombudsman found that overall, the care and treatment provided to Mr B at the First Hospital between 3 and 8 May 2022 was appropriate. The Ombudsman did not uphold complaints a) to c). The diagnosis and management of Mr B’s bowel obstruction was also considered to be reasonable and …
PSOW (Public Services Om…
Health
Upheld
Jun 2024
PSOW-202204536 — Hywel Dda University Health Board
Mr and Mrs A complained that the Health Board’s treatment and care of their daughter, Ms B, who had a learning disability (“LD”), fell below a reasonable standard. Specifically, Mr and Mrs A complained that Ms B’s diagnosis and treatment were delayed, that the nursing care she received was not …
PSOW (Public Services Om…
Health
Upheld
Oct 2024
PSOW-202203509 — Swansea Bay University Health Board
The investigation found that Mrs A was not fully aware of how unwell her husband was, and the paramedics and clinicians ought to have known this and further consideration should have been given to involving Mrs A in her husband’s care. Mrs A was not informed about the do not …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
21-003-888 — London Borough of Ealing
Summary: Mrs B has complained that the Council did not properly consider her difficulty walking when refusing a Blue Badge. The Ombudsman has found fault in that the Council did not take all relevant factors into account when conducting a telephone assessment and review. However, the Council has since carried …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
25-001-947a — Bupa Care Homes (CFH Care) Limited (25 001 …
Summary: Mrs X complained about many issues relating to the Care Provider’s management of her late parents (Mr and Mrs Y’s) care in one of its residential care homes. Some of the complaints are late. An insurance or court claim for loss or damage to valuables would be a more …
LGO (Local Government & …
Health
Nov 2025
25-002-679 — Wigan Metropolitan Borough Council
Summary: Mr X complains about the Council’s handling of Mr Y’s discharge from hospital. Mr X complains the Council did not properly complete Mr Y’s capacity assessment and arranged an unsuitable discharge care plan. Mr X says this put Mr Y at risk and impacted his physical health. We find …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
202402369 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home. A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202310183 — Lanarkshire NHS Board
C complained about the standard of care provided by the board to their parent (A). A had a complex medical history including depression for which they were on three types of anti-depressants. This was noted when A was admitted to hospital but staff failed to provide A with their prescribed …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202310085 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment provided to their spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202309997 — Grampian NHS Board
C complained about the care and treatment provided to their parent (A) during an admission to hospital. C complained that the board had failed to manage placement of a nasogastric tube (NG) correctly and did not act timeously on signs of a complication. C said that the board failed to …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202308046 — Dumfries and Galloway NHS Board
C complained about the care and treatment provided to their late spouse (A). C complained that A had an infected toe which remained unresolved despite undergoing several months of treatment. A was diagnosed with oesophageal cancer but was unable to start chemotherapy treatment because of the ongoing infection. C said …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202307773 — Lanarkshire NHS Board
C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2025