Incident commander communication training
Lack of specific training for incident commanders on the critical requirements of communication with control rooms during emergencies.
87 items
8 sources
9 inquiries
Source spread
Where this theme appears
Incident commander communication training has been flagged across 8 independent accountability sources:
64 inquiry recs
5 PFD reports
3 PPO recs
3 IOPC recs
2 IMB recs
1 Article 2 learning point
3 detention investigation recs
6 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 (64) — showing 50 strongest matches
P1-12 — Train control room operators on incident commander communications
Recommendation: All control room operators of Assistant Operations Manager rank and above receive training directed to the specific requirements of communication with the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-11 — Train incident commanders on control room communications
Recommendation: All officers who may be expected to act as incident commanders (i.e. all those above the rank of Crew Manager) receive training directed to the specific requirements of communication with the control room.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-10 — LFB review control room communications policy
Recommendation: The London Fire Brigade review its policies on communications between the control room and the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
COVID-M1.10 — Independent Statutory Resilience Body
Recommendation: The UK government should, in consultation with the devolved administrations, create a statutory independent body for whole-system civil emergency preparedness and resilience. The new body should be given responsibility for: providing independent, strategic advice to the UK government and devolved …
Gov response: Since the pandemic, significant strategic and material changes have been made to the way in which the UK and devolved governments handle crises. Considerable progress has been made against the longer-term programme to build a …
Response Unclear
In progress
COVID-M1.1 — Simplify Emergency Preparedness Structures
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil emergencies. The core structures should be: a single Cabinet-level or …
Gov response: No formal response published by this government.
Accepted
POH-19 — Publish restorative justice programme by 31 October 2025
Recommendation: By 31 October 2025, the Department, Fujitsu and the Post Office shall publish, either separately or together, a report outlining any agreed programme of restorative justice and/or any actions taken by that date to produce such a programme. For the …
Gov response: Department for Business and Trade accepts this recommendation. DBT, Post Office, and Fujitsu have jointly embarked on a postmaster-led restorative justice programme facilitated by the Restorative Justice Council. Sessions began on 23 September 2025. A …
Accepted
In progress
MAI-167 — Clarify Casualty Collection Point terminology
Recommendation: The terms Casualty Collection Point and Casualty Clearing Station are capable of being confused, one for the other, particularly in circumstances of stress. That happened on the night of the Attack. The National Ambulance Resilience Unit should consider whether different …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-158 — Guidance on commander location during incidents
Recommendation: The Home Office, the National Ambulance Resilience Unit, the College of Policing and the Fire Service College should develop guidance as to where commanders should locate during a spontaneous Major Incident. Steps should be taken to ensure that a consistent …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-151 — App for commander contact details
Recommendation: The Home Office, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should consider together whether an app giving ready access to the contact details for all on-duty and on-call commanders is feasible and, if …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-150 — Police notice of significant pre-planned events
Recommendation: The Home Office, the College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should develop a system for ensuring that the duty command structure in each police service has notice of any significant pre-planned event, …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-140 — Review Major Incident plans for interoperability
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit, individual police services and JESIP should review what changes need to be made to …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-138 — Common terminology for non-Plato hazardous zones
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should ensure that all emergency services use common terminology to describe the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-137 — Common terminology for Operation Plato zones
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should ensure that all emergency services use common terminology to describe the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-136 — Awareness of specialist capabilities across services
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and all local resilience forums should take steps to ensure, whether through multi-agency training …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-134 — Fire service notice of significant pre-planned events
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, and the Fire Service College should develop a system for ensuring that the duty command structure in each fire and rescue service has notice of any significant …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-131 — Force Duty Officer comprehensive training course
Recommendation: The Home Office, College of Policing and Counter Terrorism Policing Headquarters should ensure that all police officers to be appointed to the role of Force Duty Officer or Force Incident Manager attend a comprehensive training course dedicated to Operation Plato …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-125 — Silver Commander training for designated officers
Recommendation: The Home Office and College of Policing should ensure that any police officer whose position carries with it the expectation that they will assume a Tactical/Silver Commander role in the event of a spontaneous Major Incident (e.g. Night Silver in …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-122 — Maintain radio communications during Major Incidents
Recommendation: The emergency services should prepare, train and exercise for how they will maintain effective radio communications between emergency responders on the ground, commanders and control rooms, during the response to a Major Incident.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-79 — Train NWAS commanders on command relief procedures
Recommendation: North West Ambulance Service should train its Operational Commanders on the appropriate practice for relieving another of command and being relieved of command.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-34 — Review GMFRS information sharing during incidents
Recommendation: Greater Manchester Fire and Rescue Service should review its guidance and policies on how it receives and passes on information during a Major Incident. It is important that, for any update given, it is established when the last time the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-32 — Train GMFRS commanders in operational discretion
Recommendation: Greater Manchester Fire and Rescue Service should ensure that its commanders are adequately trained in the use of operational discretion.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-30 — Nationally accredited Force Duty Officer training
Recommendation: Given the broad command responsibilities that the Force Duty Officer or Force Incident Manager will have in the early stages of the response to a Major Incident, the Home Office and the College of Policing should develop nationally accredited training …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-21 — Firearms officer training on Operation Plato
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should ensure that all firearms officers, including firearms commanders, receive adequate training in Operation Plato, including in what such a declaration means and the demands it will place upon them. This …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-13 — Train BTP Sergeants in Bronze Commander role
Recommendation: British Transport Police should ensure that all its Sergeants are trained in what is required of a Bronze Commander in the event of a Major Incident. This will help to make sure that the first Sergeant on scene can undertake …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-12 — Train BTP Inspectors as Bronze Commanders
Recommendation: British Transport Police should ensure that all its Inspectors are trained to undertake the Bronze Commander role in the event of a Major Incident
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-4 — Appoint control room intelligence collators (Fire)
Recommendation: All fire and rescue services should consider appointing a person within their control rooms who, in the event of a Major Incident, has the sole role of gathering and collating all available information and intelligence, and sharing it internally and …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-2 — Appoint control room intelligence collators (Ambulance)
Recommendation: All ambulance service trusts should consider appointing a person within their control rooms who, in the event of a Major Incident, has the sole role of gathering and collating all available information and intelligence, and sharing it internally and externally …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
SP7 — Second Force Incident Manager support
Recommendation: All police forces that have not implemented a model providing immediate and direct support to Force Incident Managers, ideally through a second Force Incident Manager, should consider adopting such arrangements to strengthen decision‑making during critical incidents.
Response Pending
FENN-23 — Review emergency services information exchange and appoint LFB liaison officers
Recommendation: The emergency services shall review the exchange of information between themselves and London Underground during an incident, both at their controls and at the site. The London Fire Brigade should send an officer to attend at London Underground HQ as …
Unknown
HIDD-82 — BR to review and test communication systems with emergency services weekly
Recommendation: BR shall review its communication systems with the emergency services to ensure that efficient methods exist to provide and disseminate early information requiring immediate action. In the course of the review BR shall look particularly at communication between signal boxes …
Unknown
HIDD-81 — BR to equip signal boxes with direct lines and emergency dialling systems
Recommendation: BR shall complete its programme of equipping major signal boxes with direct lines to the appropriate electrical control and equipping other signal boxes with priority emergency dialling systems. Those direct lines and emergency dialling systems shall be logged and tested …
Unknown
HIDD-76 — Require BR and emergency services to maintain joint planning with table-top exercises
Recommendation: In the exercise of command and control at accident sites BR and the emergency services shall maintain their policy of joint planning supported by table-top exercises.
Unknown
P1-44 — Investigate LFB-MPS-LAS system compatibility
Recommendation: Steps be taken to investigate the compatibility of the LFB systems with those of the MPS and the LAS with a view to enabling all three emergency services' systems to read each other's messages.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-43 — Use METHANE messages for Major Incidents
Recommendation: A 'METHANE' (Major incident declared, Exact location, Type of incident, Hazards, Access, Number and type of casualties, Emergency services present and required) message should be sent as soon as possible by the emergency service declaring a Major Incident.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-42 — Designate single point of contact in control rooms
Recommendation: A single point of contact should be designated within each control room to facilitate such communication.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-41 — Establish inter-service control room communications
Recommendation: On the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-40 — Communicate Major Incident declarations to all responders
Recommendation: Each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-25 — Investigate modern control room to bridgehead communications
Recommendation: The LFB investigate the use of modern communication techniques to provide a direct line of communication between the control room and the bridgehead, allowing information to be transmitted directly between the control room and the bridgehead and providing an integrated …
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-24 — Direct control room to incident commander communications
Recommendation: The LFB develop a communication system to enable direct communication between the control room and the incident commander and improve the means of communication between the incident commander and the bridgehead.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-13 — Dedicated control room to incident commander link
Recommendation: A dedicated communication link be provided between the senior officer in the control room and the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
SP9 — NWAS Major Incident declaration procedures
Recommendation: North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how declarations are made and how they are communicated internally and to other emergency services.
Response Pending
FENN-111 — Ensure British Transport Police and Fire Brigade radio compatibility in underground stations.
Recommendation: The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire Brigade.
Unknown
FENN-30 — Review LFB instructions and training for command and control
Recommendation: The London Fire Brigade shall review its instructions and training arrangements for command and control.
Unknown
FENN-26 — Review LFB command handover procedures during major incidents
Recommendation: The London Fire Brigade shall review its procedures and criteria for handing over and assuming command during major incidents.
Unknown
HIDD-84 — Rectify high-priority deficiencies in railway communication systems and signal-post telephones
Recommendation: BR shall ensure that efficient arrangements exist to rectify as a matter of high priority any deficiencies in the communication systems involved in recommendations 81 and 82 and in signal-post telephones.
Unknown
HIDD-78 — Require each service to maintain up-to-date staff lists within inner cordon
Recommendation: Each service shall additionally maintain on site an up-to-date list of staff within the inner cordon in case evacuation is necessary.
Unknown
HIDD-77 — Require medical personnel to report to ambulance forward control unit on site
Recommendation: The ambulance service and designated hospitals shall require that all medical personnel report to the forward control unit of the ambulance service on site.
Unknown
HIDD-74 — Require emergency services to recognise Civil Police primacy in non-fire accidents
Recommendation: The emergency services shall recognise the primacy of the Civil Police authority in accidents of this kind where there is no fire. This recognition does not preclude delegation to the LFB of control at trackside.
Unknown
HIDD-73 — ACPO to establish system for extending simultaneous casualty bureau call handling
Recommendation: The Association of Chief Police Officers shall continue their efforts to establish an effective system for extending the number of calls which can be dealt with simultaneously by a casualty bureau.
Unknown
HIDD-72 — Require police casualty bureaux to be equipped with telephone queuing systems
Recommendation: Police forces shall arrange that all casualty bureaux be equipped with a telephone queuing system with a recorded message.
Unknown
PFD Reports (5)
Mark Lilliott
Concerns: Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.
Overdue
Glenda Logsdail
Concerns: A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy led to chaotic team malfunction during a critical emergency.
Response (Milton Keynes University Hospital NHS Foundation Trust): Milton Keynes University Hospital outlined actions taken, including managing involved individuals, sharing resources, implementing the Association of Anaesthetists Quick Reference Handbook, and standardising monitor configuration across theatres. They are also …
Response (Royal College of Anaesthetists): The Royal College of Anaesthetists (RCoA), in collaboration with the Association of Anaesthetists and the Difficult Airway Society (DAS), will address issues through a coordinated campaign to disseminate and embed …
Response (Department of Health Social Care): The Department of Health expresses condolences and notes actions taken by Milton Keynes University Hospital NHS Foundation Trust and the Royal College of Anaesthetists. They highlight national initiatives such as …
Response (Royal College of Anaesthetists): The Royal College of Anaesthetists (RCoA), the Association of Anaesthetists and the Difficult Airway Society launched a coordinated campaign including a dedicated webpage, educational talks, articles in members' magazines, and …
Responded
Thomas Moffett
Concerns: Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic problem.
Response (Spectrum): Spectrum CIC has held a meeting between the healthcare team, the Safer Custody Governor, and the Governing Governor at HMP Preston to develop a new system that ensures that healthcare …
Overdue
Azroy Dawes-Clarke
Concerns: Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating an ongoing risk for future critical events.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about communication and confusion during medical emergencies in prisons, confirms HM Prison and Probation Service has primacy for command and control, …
Overdue
Alexander Lewis
Concerns: Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer crew for safety.
Response (Department of Transport): The Department of Transport notes that there are no specific statutory guidance or mandatory distance regulations for yellow lines near junctions. The decision rests with the local authority, and traffic …
Response (Minister of State for Policing and Crime): The Minister explains police driver training standards, noting that decisions on crewing are operational matters for Chief Constables. Pursuits resulting in a fatality are referred to the Independent Office for …
Response (South Wales Police): South Wales Police acknowledges the concerns about crewing of Road Policing Unit officers during pursuits, but states its training and operational model are designed to ensure public safety and officer …
Responded
PPO Death in Custody Recommendations (3)
The Governor
The Governor should remind all staff that they should use the appropriate emergency medical code to communicate the nature of the emergency efficiently.
The Governor of Isle of Man Prison
The Governor should introduce a clear protocol to staff for effectively communicating a medical emergency.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that accurate information is given from the scene of an emergency incident to staff in the control room about the condition of a prisoner.
IOPC Learning Recommendations (3)
Woman killed after man drives wrong way on A13 – Essex Police, …
The IOPC recommends that Essex Police review how they can assist single crewed dispatchers when a cross border pursuit occurs. This follows an IOPC investigation which found that as the dispatcher was single crewed, they were not able to monitor …
Recommendations - Greater Manchester Police, May 2024
The IOPC recommends that Greater Manchester Police reviews their guidance on the use of force radio channels whilst a pursuit is ongoing, with the aim of reducing non-critical and non-time sensitive radio traffic from unrelated incidents whilst pursuits are underway, …
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) should include relevant content on the MPS intranet around the Joint Emergency Services Interoperability Principles (JESIP), promoting the value of JESIP to recruits and providing links to the relevant material. This …
IMB Recommendations (2)
Hull (2024)
The Board would suggest that you reinforce and actively monitor the required protocols for how and when prison officers should proactively communicate with the Board for events such as serious incidents and segregation reviews.
Governor / Director
Dovegate (2021)
Continue to encourage staff to make proper use of the BWCs which are now available and worn by frontline staff. Staff should be reminded that their value as de-escalation and evidential tools is only useful if they are turned on. This is essential for in-cell interaction where no other CCTV source is available.
Governor / Director
Detention Investigations (3)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 3
those likely to represent the Immigration Service in the Gold suite at Prison Service headquarters should attend a number of Prison Service incidents to familiarise themselves with general processes and practices.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 2
IND and the Prison Service give further consideration to contingency arrangements to ensure greater clarity and proper lines of accountability, and which, ideally, give IND ultimate authority and responsibility for the management of incidents. Failing this, I recommend a small cadre of potential Gold Commanders be prepared/trained specifically for handling …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 1
GSL reviews deployment of staff to incidents and the use of ‘talk through’ mode on the radio allowing officers to self deploy.
Immigration Detention
LGO / SPSO Decisions (6)
201101523 — Lothian NHS Board
Mr C's son was an in-patient at a clinic. Mr C raised concerns about staff accusations that he and his partner made inappropriate and/or racial comments about or to nursing staff. Mr C claimed that when he challenged the accusations, staff refused to detail what comments had caused offence or …
SPSO (Scottish Public Se…
Health
Not Upheld
Nov 2011
201005329 — Greater Glasgow and Clyde NHS Board
Ms C, an advice worker, complained to us on behalf of Mrs A, about the board. She said that they had failed to respond appropriately to Mrs A's sudden drop in blood pressure following an operation on her eye under general anaesthetic. During the post-operative period of the eye operation, …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2011
201204853 — A Medical Practice in the Forth Valley NHS …
Mr C complained that his medical practice refused to update him on changes in his son (Master A)s medical file, about which his estranged wife had not told him. Mr C also complained that the practice had prevented him from transferring his son to an alternative practice in the area. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013
201204558 — Grampian NHS Board
Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2013
201204522 — Glasgow Housing Association Ltd
Mr C needed a lot of support with housing matters. He was asked to go to his local housing office about a rent matter and called in, expecting to see one of two officers he had dealt with before, but they had both retired. He was introduced to his new …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2013
201203006 — Orkney NHS Board
Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013