Inconsistent Healthcare Data Infrastructure
Lack of a consistent and mature data infrastructure across NHS providers, hindering technological adoption and data sharing.
355 items
13 sources
10 inquiries
Source spread
Where this theme appears
Inconsistent Healthcare Data Infrastructure has been flagged across 13 independent accountability sources:
36 inquiry recs
117 PFD reports
153 committee recs
9 CQC actions
3 HMICFRS recs
1 ICIBI rec
1 IOPC rec
12 NAO recs
2 IMB reports
11 IMB recs
2 detention investigation recs
1 PHSO decision
7 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 (36)
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: Department for Business and Trade rejects this recommendation as it conflicts with the principle of providing "full and fair" redress. Postmasters should retain the choice between continuing with the dispute resolution procedure or transferring to …
Not Accepted
1 — Single consultant data repository
Recommendation: We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data – for example, how many times a consultant has performed a particular …
Gov response: Accepted in principle. The government is improving data flows to CQC and GMC to give them better oversight of consultants' full scope of practice. NHS England is developing a workforce repository and working with partner …
Accepted in Part
No update 2+ yrs
IHRD-91 — Synchronise Patient Safety Systems
Recommendation: The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information.
Gov response: Work progressing on synchronisation of patient safety incident systems across organisations.
Accepted
No update 2+ yrs
F272 — Improving and assuring accuracy
Recommendation: There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and Social Care Act 2012, it should be used as soon …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F271 — Improving and assuring accuracy
Recommendation: To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should work towards establishing such status for them or any successor …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F270 — Improving and assuring accuracy
Recommendation: There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other outcome indicators. In particular, there could be benefit from consideration …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F269 — Improving and assuring accuracy
Recommendation: The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F262 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against patient safety and minimum quality standards; Effective real-time information of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F260 — Information standards
Recommendation: The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
IBI-7f(iii) — Blood Tracking Systems Funding
Recommendation: Establishing the outcome of every transfusion: That funding for the provision of enhanced electronic clinical systems in relation to blood transfusion be regarded as a priority across the UK.
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted in Part
No update 2+ yrs
IBI-7f(ii) — NHSBT Transfusion Outcome Funding
Recommendation: Establishing the outcome of every transfusion: To the extent that the funding for digital transformation does not already cover the setting up and operation of this framework, bespoke funding should be provided.
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted
No update 2+ yrs
IBI-7f(i) — Transfusion Outcome Framework
Recommendation: Establishing the outcome of every transfusion: That a framework be established for recording outcomes for recipients of blood components. That those records be used by NHS bodies to improve transfusion practice (including by providing such information to haemovigilance bodies). Success …
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted
No update 2+ yrs
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
BRIS-154 — Invest in world-class IT systems for efficient healthcare data collection and feedback
Recommendation: The need to invest in world-class IT systems must be recognised so that the fundamental principles of data collection, validation and management can be observed: that data be collected only once; that the data be part and parcel of systems …
Unknown
BRIS-152 — Review incentives for data quality; include trust performance in validation process
Recommendation: The system of incentives and penalties to encourage trusts to provide complete and validated data of a high quality to the national database should be reviewed. Any new system must include reports of each trust’s performance in terms of the …
Unknown
BRIS-151 — Improve status, training, and qualifications of clinical coding staff for data accuracy
Recommendation: Systems for clinical audit and for monitoring performance rely on accurate and complete data. Competent staff, trained in clinical coding, and supported in their work are required: the status, training and professional qualifications of clinical coding staff should be improved.
Unknown
BRIS-150 — Support Hospital Episode Statistics as a reliable national resource for monitoring outcomes
Recommendation: The Hospital Episode Statistics database should be supported as a major national resource which can be used reliably, with care, to undertake the monitoring of a range of healthcare outcomes.
Unknown
BRIS-149 — Improve clinician confidence in Patient Administration Systems data through collaboration
Recommendation: Steps should be taken nationally and locally to build the confidence of clinicians in the data recorded in the Patient Administration Systems in trusts (which is subsequently aggregated nationally to form the Hospital Episode Statistics). Such steps should include the …
Unknown
BRIS-148 — Implement a single, trusted system for collecting clinical and administrative data
Recommendation: The current ‘dual’ system of collecting data in the NHS in separate administrative and multiple clinical systems is wasteful and anachronistic. A single approach to collecting data should be adopted, which clinicians can trust and use and from which information …
Unknown
BRIS-109 — Create single, unified system for reporting and analysing sentinel events
Recommendation: There should a single, unified, accessible system for reporting and analysing sentinel events, with clear protocols indicating the categories of information which must be reported to a national database.
Unknown
IHRD-27 — Electronic Patient Information Systems
Recommendation: Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
Gov response: Electronic care record and digital health programmes progressing across Northern Ireland.
Accepted
No update 2+ yrs
F267 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F266 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard to the views of patient groups and the public about …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F265 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on the efficacy of treatment in that specialty, for publication and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F261 — Information standards
Recommendation: The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F258 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F36 — Use of information for effective regulation
Recommendation: A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
COVID-M4.4 — Proportionate Access to Linked Healthcare Records
Recommendation: The UK government and devolved administrations should work together, with their respective health delivery services, to facilitate and coordinate regulatory bodies' access to healthcare records in order to make the post-authorisation safety monitoring of new vaccines and therapeutics more efficient. …
Gov response: No formal response published by this government.
Unknown
IBI-7b — Transfusion 2024 Review Progress
Recommendation: Review of progress towards the Transfusion 2024 recommendations: Progress in implementation of the Transfusion 2024 recommendations be reviewed, and next steps be determined and promulgated; and that in Scotland the 5 year plan is reviewed in or before 2027 with …
Gov response: UK Government Progress against Transfusion 2024 recommendations has been initially reviewed jointly by NHS England and NHSBT and a wider four nations stakeholder review is being scheduled. The draft report was discussed with key stakeholders …
Accepted
No update 2+ yrs
IBI-7a(iii) — Transfusion Performance Benchmarking
Recommendation: Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management
Gov response: In relation to the recommendation on standardising and benchmarking, a review of current benchmarking practices and associated data collection and ongoing intelligence and analysis requirements, including model health dashboard and national clinical audit, has been …
Accepted
No update 2+ yrs
WATE-(70) — Strengthen national statistics services in Wales for management information system
Recommendation: The national statistics services in Wales should be strengthened to provide a comprehensive management information system.
Unknown
F268 — Resources
Recommendation: Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F264 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F263 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
IBI-9f — National Haemophilia Database Support
Recommendation: That the National Haemophilia Database, run by the UKHCDO, merits the support of additional central funding.
Gov response: UK Government Recommendation 9f: NHS England currently provides ‘central’ funding of approximately 40% of the total annual cost for running the National Haemophilia Database. A task and finish group relating to the database has been …
Accepted
No update 2+ yrs
P2-25 — Postgraduate training governance clarity
Recommendation: Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue …
Gov response: This recommendation is under consideration.
Response Unclear
PFD Reports (117) — showing 50 strongest matches
John Morgan
Concerns: Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" system pose risks to patient care.
Response (Welsh Government): The Welsh Government requested that Health Boards and Trusts review the incident and make changes as appropriate. The Chief Medical Officer and Chief Nursing Officer will write to all Health …
Overdue
Jude Augustus Gordon
Concerns: Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Response (Department of Health): The Department of Health acknowledges the concerns, noting existing work on a national early warning score (NEWS) and the use of computerised systems in some Trusts. However, it states that …
Responded
Georgina Swindells
Concerns: The coroner identified concerns regarding delays in image transfer, a lack of available data to investigate the issue, the absence of an image transfer backup process, and the apparently erroneous scan report, raising the possibility of misreporting in the future.
Overdue
Katie Davies
Concerns: Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed appropriate care.
Response (Department of Health): The Department of Health will send a safety alert to all Trusts in England about potential 'blind spots' for bleepers and pagers, and the National Clinical Director for Stroke at …
Responded
Samuel Openshaw
Concerns: Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.
Overdue
Ralph Goslin
Concerns: An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
Response: The trust has commissioned specialist epilepsy training from the National Neurological Commissioning Support Unit, working with the National Epilepsy Society, across inpatient and residential services. The process for sharing recommendations …
Responded
Peter Hinchliffe
Concerns: Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing risk.
Overdue
Ronald Perry
Concerns: Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.
Response: The University Health Board states that its radiology service operates a full service during weekday hours, with emergency on-call service at all other times, and a CT scan would have …
Responded
Shayla Walmsley
Concerns: Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem analysis of medical devices hinder investigations and timely safety interventions.
Overdue
Suzanne Cammell
Concerns: Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.
Response (Thames Valley Police): Thames Valley Police reviewed the communication between their control room and Gloucestershire Police regarding the deceased. They clarified the information that was shared and noted that Gloucestershire Police had previous …
Overdue
Evelyn Smith
Concerns: Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective data entry in GP records.
Overdue
Alan Jones
Concerns: Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented important patient conditions from being clearly highlighted as alerts.
Response (Department of Health): The Department of Health explains the GP Systems of Choice (GPSoC) scheme, through which the NHS funds the provision of GP clinical IT systems in England.
Overdue
Lexie Harrison
Concerns: A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.
Response (The Leeds Teaching Hospitals NHS Trust): The Trust shared the coroner's report with relevant staff and clarified their existing guidelines for managing bleeding oesophageal varices, including resuscitation, antibiotic use, Sengstaken tube placement, and banding procedures. They …
Response (Cardiff and Vale University Health Board): The UHB acknowledges the coroner's concerns regarding the lack of standardized practices for paediatric endoscopy procedures, but states that they are unable to take the concerns forward themselves and suggest …
Overdue
Richard Jones
Concerns: Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.
Response (Ministry of Defence): The Ministry of Defence is adding guidance to JSP 950 Leaflet 2-7-2 regarding medical information handling, entitlement of service personnel to NHS services, liaison between DCMHs and local NHS services, …
Response (Avon and Wiltshire NHS Trust): The Trust will conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces to explore the issues raised in the report and review relevant policies …
Response (Department of Health2): The Department of Health is in discussion with the Ministry of Defence and NHS England to address concerns about mental health care for armed forces members, and is working to …
Response (Salisbury NHS Trust): Following the case review, the SFT Emergency Department implemented a new mental health risk assessment tool, improved information sharing with mental health services, and implemented a system to record and …
Response (UK Health Security Agency): Public Health England states its role is to help the public health system achieve 'public health parity' for mental health. They are aware the Department of Health is in discussion …
Responded
Simon Costin
Concerns: Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication and care continuity for mental health patients across different trusts.
Response (NHS England): NHS England notes the Leicestershire Partnership Trust has addressed standardised mental health assessments and has specific learning points from this incident including the use of translators and liaison with Primary …
Responded
Paige Bell
Concerns: Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.
Response (Northumberland Tyne Wear NHS Trust): The Trust believes there was confusion about contradictions in the observation policy. While acknowledging improvements are needed in recording information, they state that information was shared and available to decision-makers.
Response (Department of Health): The Department of Health acknowledges the concerns regarding electronic patient records, national policy on patient engagement and observation, and NICE guidelines for Borderline Personality Disorder. They describe existing systems and …
Responded
Hilda Harris
Concerns: The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.
Response: The University Health Board has developed and implemented a Corrective Action Plan for Improvement, with actions taken forward by the Primary Community & Localities Directorate.
Overdue
Jayne Jowett
Concerns: PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for GP collaboration or for communicating patient physical conditions to GPs.
Response (Partnership in Care): All qualified staff at relevant sites have been retrained on NEWS following the inquest, and this will form part of the induction training. Annesley House has a service level agreement …
Overdue
George Richardson
Concerns: Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Response (Department of Health): The Department of Health acknowledges the concerns, highlights existing national guidance on catheterisation from NICE and RCN, and states that ensuring staff are aware of guidance and how to seek …
Responded
Elizabeth Godwin
Concerns: Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.
Response (Royal United Hospitals Bath NHS Trust): Royal United Hospitals Bath NHS Foundation Trust (RUH) has implemented additional resource for Mental Health Services and amended the Mental Health Assessment Matrix. All junior doctors, Emergency Nurse Practitioners and …
Response (Wiltshire Council): Wiltshire Council describes planned discussions between Wiltshire Council (WC) and AWP to be held to clarify roles and responsibilities and ensure that a process is followed.
Response (Avon and Wiltshire NHS Trust): Avon and Wiltshire NHS Trust highlights that the Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the CPA process including assessment …
Responded
Masoud Ghaderi
Concerns: Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Response (Avon and Wiltshire NHS Trust): The Trust Engagement and Observation Policy will be reviewed to ensure consistent recording of engagements. The Clinical Executive has commissioned an audit of reviewing risks across inpatient units and will …
Overdue
Michael Quinn
Concerns: Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.
Overdue
Harry Pryal
Concerns: A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.
Response (Department of Health): The response acknowledges concerns, noting that local providers are best placed to address system issues. It highlights the move to digital care records and the development of standards for clinical …
Response (Wigan Borough CCG): The CCG has requested that SBP have a service agreement in place with a provider for physiotherapy and occupational therapy; SBP has confirmed that all requests for these therapies will …
Response (5 Borough Partnership NHS Trust): The Trust has developed a standardised proforma for transfer between Trusts, shared with colleagues in Wrightington, Wigan and Leigh NHS Foundation Trust and discussed at the Wigan Medical Staff Committee. …
Response (Wrightington Wigan and Leigh NHS Trust): The Trust has developed a proforma for telephone advice, has updated the radiology information system and implemented 'hot reporting' during weekdays. Specialist Radiographer chest X-ray reporting has been introduced.
Responded
Edward Gascoigne
Concerns: The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.
Response (Response ny Department of Health): The Department of Health describes the Summary Care Record (SCR) system and planned enhancements, stating that it is designed to improve access to patients’ GP records.
Responded
Antony Briggs
Concerns: Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.
Response (A Briggs): The Trust will strengthen communication between secretarial teams at Stepping Hill and Buxton to ensure radiology reports are available at both sites simultaneously. They will develop a standard operating procedure …
Responded
Amy Cooper
Concerns: Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
Overdue
Anna Masson
Concerns: A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.
Response (Southern Health NHS Foundation Trust): The Trust is reviewing its CMHT Standard Operating Procedure (SOP) to standardize screening processes across all teams, ensuring appropriate staff expertise and multi-disciplinary team discussions. A randomised audit will be …
Responded
Leslie Carswell
Concerns: Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.
Response (Sandwell and West Birmingham Hospitals): The Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and documentation requirements. All radiographers are being trained …
Overdue
Captain James Bedforth
Concerns: Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding lower leg scanning for DVT, but refers the matter to NICE and the Royal Society of Medicine Venous Forum for further …
Overdue
Natalie Thornton
Concerns: Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a risk to patient safety.
Response (Department of Health): NHS Improvement is appointing a Clinical Lead for diabetes inpatient care to review insulin pumps and current support for users, with the review expected to be completed in late 2018. …
Overdue
Daniel Maher
Concerns: Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.
Overdue
David Hamilton
Concerns: Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.
Response (Pennine Care NHS Trust): Healthy Minds service provides treatment options and offers advice. A log is kept on the system and patients can be "stepped up" during therapy. GPs can request consideration for assessment …
Response (Grosvenor Medical Centre): The practice escalated concerns about mental health support to the Clinical Commissioning Group. They escalated the matter to the Mental Health Clinical Lead and Head of Mental Health regarding the …
Responded
Patrick Clifford
Concerns: Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.
Overdue
Michael Giles
Concerns: Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.
Response: The Trust has undertaken an audit of record keeping, is developing a clinical records keeping video, and is providing human factors training; it will continue to audit patients unexpectedly brought …
Responded
Gwendoline Halfpenny
Concerns: County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.
Response (University Hospitals of North Midlands NHS Trust): The Trust will re-share and re-communicate the SOP regarding consultant referrals to all staff. A Deputy Medical Director has been appointed with specific responsibility for County Hospital to speed up …
Responded
Mildred Griffiths
Concerns: The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.
Response (Avery Health Group): Avery Health Group states they will continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.
Responded
Edwin Hooper
Concerns: Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.
Response (Manchester University NHS Trust): The hospital has implemented a robust escalation and dissemination plan for CT scanner downtime, including senior managers on call, out-of-hours team reminders, and posters in clinical areas. Training on NICE …
Responded
Gail Bannister
Concerns: The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with the care team.
Response (Response Worcestershire Health and Care NHS Trust): Worcestershire Health and Care NHS Trust is installing a new telecommunications system with call forwarding at Studdart Kennedy House, with a survey completed and a capital bid to be submitted; …
Responded
Angela Byrne
Concerns: W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with inconsistent records.
Overdue
Alfie Scambler-Holt
Concerns: The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.
Overdue
Robert Wrinch
Concerns: The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist shortages also contributed to backlogs.
Overdue
Janice Davies
Concerns: Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.
Response: The Health Board has developed a corrective action plan and implemented actions including a registered nurse reflection, a standard operating procedure for oral opioid medication use, and RRAILS discussions and …
Responded
Edward Hearn
Concerns: A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer guidance on cardiac monitoring.
Response (King's College Hospital NHS Foundation Trust): The case is being used to highlight to ED medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up, and work is ongoing to highlight the …
Response (AMGEN): Amgen believes that cardiac monitoring guidance is already definitively outlined in the prescribing information for Kyprolis, and that no further revisions to the SmPC are required. However, they will continue …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA considered whether the statutory information currently provided by the marketing authorisation holder for prescribers and patients on the safe use of carfilzomib is adequate. The statutory product information …
Responded
Susan Longden
Concerns: The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Response (NHS England): NHS Digital acknowledges that the question about a recent surgical procedure or operation is not specifically asked in a sub-section of their abdominal pain pathways and are reviewing how this …
Responded
Deborah Hopkinson
Concerns: Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.
Response (Northern Care Alliance NHS Trust): The Trust plans to incorporate awareness of Cushing's Disease into annual training for Core Medical Trainees, using the case as a study, and will discuss the case at local and …
Responded
Tarek Chowdhury
Concerns: There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.
Overdue
Kevin McDonald
Concerns: Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.
Overdue
Alexander Davidson
Concerns: NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Response (NHS England): NHS Pathways reviewed the question regarding dark brown or black vomit and concluded removing 'coffee-grounds' could result in over-referral. As part of routine review and governance procedures, they are conducting …
Response (National Institute for Health and Care Excellence): NICE will reconsider the scope of their guideline on pancreatitis (NG104) when it is next reviewed, to consider lipase/amylase testing in young people.
Overdue
Maia Strachan
Concerns: The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.
Response (Maia Strachan): The Trust has reviewed current training around documentation standards and it is provided as part of the PROMPT annual training. An ongoing monthly audit of notes will occur, and a …
Overdue
Mark Jarvis
Concerns: The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Overdue
Committee Recommendations (153) — showing 50 strongest matches
#16 —
Recommendation: NHSE&I must streamline the data collection process to reduce the burden for trusts. The Department must ensure that insights collected by all bodies are collated in a coordinated manner and shared across organisations in a timely manner. As part of …
Gov response: 70. We accept this recommendation in part. 71. We agree that data collection should be streamlined, and that insights collected should be collated in a coordinated way and shared across organisations in a timely manner. …
Not Addressed
#2 — Recommend a trial of a centralised Secure Data Environment and simplify ethical governance
Recommendation: Should our successor Committee wish to explore the reform of the UK health data strategy, we recommend it considers: • Investigating the replication of the academic model of open and competitive funding to solve problems and develop Privacy Enhancing technologies …
No Published Response
#26 — NHS still lacks consistent data infrastructure and technological maturity, delaying productivity gains.
Recommendation: We asked what was being done to improve productivity through the use of new technologies. NHSE told us the NHS currently lacks a consistent data infrastructure and that NHS providers varied in terms of their levels of technological maturity.50 NHSE …
Gov response: The government disagrees with the Committee’s recommendation. 7.2 It is right that all patient records in the NHS should be digitised. In 2025-26 Operating Planning Guidance, NHSE and DHSC has prioritised investment in: • running …
Not Accepted
#7 — Publish plans to reduce NHS paper reliance and set deadline to end fax machines.
Recommendation: Despite ambitions to improve productivity through the introduction of new technologies, the switch to digital in parts of the NHS has been glacially slow. Digital and technological improvements could have a transformative effect on the NHS. However, NHSE’s investment in …
Gov response: The government disagrees with the Committee’s recommendation. It is right that all patient records in the NHS should be digitised. In 2025-26 Operating Planning Guidance, NHSE and DHSC has prioritised investment in: • running and …
Not Accepted
#31 — Accuracy of criminal and civil court data, including remand population, remains questionable
Recommendation: Despite these assurances, we concur with a request from the Law Society of England and Wales in its written submission to us for confirmation from MoJ that other data and statistics across the criminal and civil courts are not similarly …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Recommendation implemented: March 2025 7.2 The external assurance review of the process and methods used to produce Crown Court caseload statistics concluded that MoJ can have a …
Accepted
#30 — Crown Court caseload data previously unreliable due to Common Platform errors
Recommendation: MoJ confirmed that it had identified three factors that caused it to pause publication of its Crown Court caseload data from June to December 2024. It had found that case records in Common Platform (the new digital case management system …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Recommendation implemented: March 2025 7.2 The external assurance review of the process and methods used to produce Crown Court caseload statistics concluded that MoJ can have a …
Accepted
#7 — Assure accuracy of criminal justice datasets and set out scope for courts' digitisation.
Recommendation: Despite MoJ assuring us that it has rectified the processing errors that led to it publishing inaccurate Crown Court statistics, we remain concerned that other datasets within the criminal justice system may be affected by the same quality and accuracy …
Gov response: The government agrees with the Committee’s recommendation. the courts and tribunals, working in collaboration with the judiciary. MoJ is in the early stages of proving the effectiveness of transcription in Immigration Tribunals, as well as …
Accepted
#44 — Disconnected health data systems and lack of central repository hinder effective antimicrobial stewardship.
Recommendation: Lord O’Neill told us there is an underlying data problem in the health sphere, with many data systems not connecting properly.111 Better data in health would make it easier for clinicians making decisions on infection management and prescribing antimicrobials. The …
Gov response: 9.1 The government agrees with the Committee’s recommendation Target implementation date: Autumn 2026 9.2 The government is working to strengthen data collection and sharing across One Health sectors. 9.3 UKHSA launched a new data dashboard …
Accepted
#24 — Diagnostics require further investment and greater integration across the entire health system.
Recommendation: Lord O’Neill told us that although DHSC and its arm’s-length bodies have done a decent job in some key areas, they have not really progressed diagnostics. He is of the view that diagnostics should be embedded across the entire health …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross- sector working to develop diagnostics as …
Accepted
#23 — Lack of progress on diagnostics target due to data limitations; no new quantitative goal.
Recommendation: The 2019–24 NAP had a target to be able, by 2024, to report on the percentage of prescriptions supported by a diagnostic test or decision support tool. However, this was not achieved due to continuing limitations with data, including diagnostic …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross- sector working to develop diagnostics as …
Accepted
#22 — Inadequate diagnostic tests hinder clinicians from reducing inappropriate antimicrobial prescribing effectively.
Recommendation: Better use of diagnostic tools can reduce inappropriate prescribing.56 Diagnostic tools are those which can help diagnose what infection a patient has, thereby helping clinicians determine with accuracy whether a patient needs an antimicrobial treatment and, if so, which one.57 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross- sector working to develop diagnostics as …
Accepted
#4 — Mandate health bodies to demonstrate progress in using diagnostic tools for AMR over two years.
Recommendation: DHSC has made slow progress in implementing diagnostic tools that could help reduce AMR. Inappropriate prescribing of antibiotics in primary care is estimated to be around 20% of antibiotic prescriptions, which is too high and could drive AMR. ‘Inappropriate’ includes …
Gov response: The government agrees with the Committee’s recommendation. sector working to develop diagnostics as a tool to tackle AMR. DHSC, through National Institute for Health and Care Research (NIHR), has invested over £18 million into research …
Accepted
#9 — Department struggles monitoring sector engagement with inaccessible digital systems and inconsistent records
Recommendation: We asked the Department about its ability to monitor its engagement with economic sectors, given that officials do not consistently record their interactions with companies, and its digital system — DataHub — is not accessible across the whole of Whitehall.17 …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 The department developed the whole of the Industrial Strategy in partnership with other departments, with Sector Plans led by relevant departments. This ongoing programme …
Accepted
#5 — UK Government has not provided Wales-specific data on IHT reform impact.
Recommendation: We are concerned that the UK Government has been unable to provide any clarity on the specific impact of its proposed IHT reforms in Wales or supply any Wales-specific data. Only UK-wide figures for farming estates potentially liable to pay …
Gov response: The Government understands the concerns raised by the farming community in Wales. UK Government Ministers have visited farms across the country and met with relevant organisations, including NFU Cymru and the Famers’ Union of Wales, …
Not Addressed
#4 — Establish a shared geospatial and environmental data platform for cross-government use
Recommendation: Within 12 months of this report, the Government should establish a shared geospatial and environmental data platform, integrated with a case working system. This should be designed for use across government departments, arms-length bodies and local planning authorities to aid …
Gov response: 10. We are consulting on changes to the presumption in favour of sustainable development as part of our wider consultation on changes to the NPPF that was published on 16 December 2025. The details of …
Under Consideration
#3 — Existing data platforms remain siloed, hindering cross-organisational sharing of environmental data
Recommendation: Improved data sharing is a fundamental enabler of efficient and effective cross-organisational work to deliver sustainable housing. While there is evidence of cross-departmental working between DEFRA and MHCLG on planning, nature and housebuilding, the evidence we have taken suggests that …
Gov response: 9. The Government is committed to delivering a clearer, faster, more accessible plan-making system to speed up the preparation of local plans and ensure that communities benefit from up-to-date plans across England. This is to …
Under Consideration
#24 — Fully integrated multi-species livestock tracing system not expected until winter 2027 with uncertain funding
Recommendation: Between 2019 and March 2025, the Department has spent £181 million on the programme and some services have been developed including a new sheep, goat and deer tracing service.33 However, the Department does not expect to have a fully integrated …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2027 6.2 The work to develop a multi-species livestock tracing system is making progress according to the revised timetable. 6.3 From summer 2026, …
Accepted
#23 — Multi-species livestock tracing system programme experienced significant resets due to technical issues
Recommendation: The Department first started work to create a digital, multi-species, UK-wide tracing system in 2013 and acknowledged that it has been working on this for a long time. It explained that the original concept of using an off- the-shelf solution …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2027 6.2 The work to develop a multi-species livestock tracing system is making progress according to the revised timetable. 6.3 From summer 2026, …
Under Consideration
#22 — Current UK animal tracing systems are fragmented, old, and fragile
Recommendation: Livestock movements in England are significant. For example, there are around 20 million movements of sheep to or from different farms, livestock markets, collection centres, and to abattoirs each year. These movements increase the risk of spreading disease. Being able …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2027 6.2 The work to develop a multi-species livestock tracing system is making progress according to the revised timetable. 6.3 From summer 2026, …
Accepted
#18 — APHA's outdated paper-based systems and processes cause significant inefficiency and delays.
Recommendation: APHA acknowledged that its systems and processes are outdated and require modernisation. For example, its vets in the field must complete paper-based forms, which are scanned and manually deciphered before being added to a database. APHA also cited the example …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: February 2027 4.2 The Delivering Sustainable Futures (DSF) Programme has a £10.9 million funding provision for 2025-26 and approximately the same year on year …
Accepted
#17 — EU exit reduced timely access to detailed animal disease intelligence for the UK.
Recommendation: The Department explained that following EU exit, the UK lost access to the EU’s Animal Diseases Information System which provided almost real-time intelligence on EU animal diseases. While the UK has access to an international intelligence system provided by the …
Under Consideration
#6 — Ensure progress and devolved alignment of the multi-species livestock tracing system
Recommendation: The Department’s progress delivering a multi-species livestock tracing system has been extremely slow and may not provide an integrated system for the UK. Tracing animal movements quickly—to understand where disease may have spread—is key in responding effectively to contain an …
Gov response: The government agrees with the Committee’s recommendation. according to the revised timetable. From summer 2026, the department will introduce changes to cattle identification, registration and reporting that will improve the government’s ability to respond effectively …
Accepted
#22 — FCDO lacks crucial data on capital project delivery track record and performance.
Recommendation: FCDO completed or started work on 200 capital projects between April 2018 and November 2024, with a total value of £850 million. FCDO does not hold data on its track record in delivering its projects, but several high-profile projects have …
Gov response: 5. PAC conclusion: Some FCDO high-profile estate projects have run significantly over time and budget. 5. PAC recommendation: FCDO should immediately restart centrally collecting and analyzing lessons learned from its estate capital projects, to ensure …
Accepted
#20 — FCDO acknowledges inadequate digital estate management, planning a comprehensive workplace system by 2028.
Recommendation: We note that modern property IT portals which are tried and tested are readily available. FCDO accepted that it is an organisation whose digital management of its large estate portfolio is not up to scratch and that it needs to …
Gov response: 4. PAC conclusion: FCDO does not have all the data it needs to manage its estate effectively. 4. PAC recommendation: Alongside its Treasury Minute response, FCDO should write to the Committee setting out the progress …
Accepted
#19 — FCDO's disparate and unintegrated IT systems hinder central collection and effective management of estate data.
Recommendation: Even if staff at posts start collecting estate data, FCDO faces a challenge collecting this data centrally so it can use it to manage its estate portfolio.50 FCDO uses a range of different IT systems to manage its estate. FCDO …
Gov response: 4. PAC conclusion: FCDO does not have all the data it needs to manage its estate effectively. 4. PAC recommendation: Alongside its Treasury Minute response, FCDO should write to the Committee setting out the progress …
Accepted
#17 — FCDO's federated structure and inadequate post resources hinder comprehensive estate data collection.
Recommendation: FCDO told us that it is very challenging to collect the data it needs to manage its estate as it is a “federated organisation,” and its central estate function relies on staff at each of its 282 posts to provide …
Gov response: 4. PAC conclusion: FCDO does not have all the data it needs to manage its estate effectively. 4. PAC recommendation: Alongside its Treasury Minute response, FCDO should write to the Committee setting out the progress …
Accepted
#4 — Report FCDO progress on embedding quality estates data collection and implementing an integrated management system.
Recommendation: FCDO does not have all the data it needs to manage its estate effectively. FCDO has developed its central IT systems separately and they are not integrated with each other, or with systems at overseas posts. Overseas posts are responsible …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The FCDO has written to the Committee alongside the publication of this Treasury Minute.
Accepted
#4 — Require NHSE and Department to set out plans for elective care digital transformation and IT connectivity.
Recommendation: We are not confident that the Department is being realistic about the immense effort needed to reduce NHS elective care waiting times, and see a significant risk that digital solutions are being treated as a ‘cure- all’ as the 10 …
Gov response: The government agrees with the Committee’s recommendation Recommendation implemented The government is providing record investment in the health and social care system. The 10 Year Health Plan is affordable within the Department of Health and …
Accepted
#9 — BBC's digital account data cannot directly support licence fee enforcement activities.
Recommendation: We queried why digital audience engagement through the accounts necessary to use iPlayer cannot support more digital licence fee enforcement activities. The BBC told us that its household-address based licensing system does not match individual based BBC account data, so …
Gov response: The government agrees with the Committee’s recommendation. requested by the Committee, noting that the negotiations for a Sanitary and Phytosanitary (SPS) agreement with the EU, and timescales involved, will need to be integrated into development …
Accepted
#8 — Department lacks up-to-date information on children's care provision, demand, and available places.
Recommendation: The Children’s Commissioner told us that there needs to be a much tighter grip on the amount and type of provision needed and where.13 The Department lacks up-to-date information on the support children need, the demand for places and places …
Response Pending
#21 — Fragmented police HR and other systems lack a firm plan for national simplification.
Recommendation: We sought reassurances that the Home Office was considering simplifying police systems, such as those used in human resources. The Home Office recognised police forces use many different systems and it is a highly fragmented picture. It told us that …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Police Efficiency and Collaboration Programme (PECP) has an annual cashable efficiencies target of £354 million by 2028-29 and a non-cashable efficiencies target of …
Response Pending
#7 — Fragmented police data hinders understanding of financial risks and impact on productivity.
Recommendation: We asked the Home Office whether it has the data it needs to understand the financial risks facing police forces and the impact that this has on police productivity.9 The Home Office said there are multiple datasets scattered across bodies …
Gov response: 1. PAC conclusion: The Home Office does not have sufficient data on the financial resilience or performance of police forces. 1. PAC recommendation: By July 2026, the Home Office should write to us setting out …
Accepted
#3 — Establish a national system for sharing and analysing clinical negligence data to improve patient safety.
Recommendation: We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. Behind every clinical negligence claim is a tragic incident of patient harm. We were disappointed …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented This work is underway. NHS England is actively developing and evaluating AI models on Learn from Patient Safety Events (LFPSE) data, including topical analysis and novelty …
Accepted
#45 — Publish regular, transparent data on prison healthcare access and outcomes for accountability
Recommendation: NHS England, or its successor, should publish regular, transparent data on healthcare access and outcomes across the prison estate. This data should be used to monitor progress against the principle of equivalence and to hold both NHS England or its …
Gov response: Accept. As with recommendation 24, we are committed to ensuring that people in prison have access to an equivalent standard, range and quality of health care in prisons to that available in the wider community. …
Accepted
#22 — Mandate Pharmacy First evaluation assesses digital systems' data sharing for patient safety and care.
Recommendation: We recommend that the ongoing evaluation of Pharmacy First includes an assessment of the extent to which pharmacy and general practice digital systems are enabling the necessary data sharing to protect patient safety and ensure continuity of care.
Gov response: Accept NHS England is committed to ongoing monitoring of all services, including Pharmacy First to understand ways we can improve access and support provided. For Pharmacy First, this includes oversight of medicine supply, claims systems …
Accepted
#21 — Require Government to detail progress on Pharmacy First digital product rollout and interoperability.
Recommendation: When responding to this report, we ask that the Government sets out what progress has been made on rolling out the full digital product for the documentation of Pharmacy First consultations, including the percentage of community pharmacies that have fully …
Gov response: Accept The full suite of digital capabilities for Pharmacy First is designed to make it easier for frontline staff to refer, consult, record outcomes, and report. NHS England policy is not to enable community pharmacies …
Partially Accepted
#18 — Publish annual official estimates of delayed discharge costs to the NHS, broken down by reason
Recommendation: We recommend that the Department provides an official estimate of how much delayed discharges are costing the NHS, broken down by the reason for the delay and including costs associated with the beds themselves, staff time and wider activity that …
Gov response: We agree that publishing cost estimates broken down by delay reason would in principle improve transparency about the impact of delayed discharges. There are some methodological challenges involved in estimating costs attributable to delayed discharge, …
Under Consideration
#3 — Develop robust methodology for measuring care's impact on people's lives, health, and the economy.
Recommendation: The Government must also develop a robust methodology for measuring the impact of care on people’s lives, the wider health system, and the economy. As well as supporting the case for reform, such methodology would help councils to deliver outcome-based …
Gov response: The government considers that any future policy changes or fiscal decisions relating to the workforce should be accompanied by existing procedures for impact assessments rather than a new form of cross-government impact assessment. The government …
Not Accepted
#2 — Publish annual assessment of unmet care needs for adults, including methodology and supporting data.
Recommendation: The Government should publish an annual assessment of the level of unmet care needs for both older adults and working age disabled adults, publishing its methodology and supporting data to ensure transparency and allow for scrutiny. (Recommendation, Paragraph 21)
Gov response: Adult social care outcomes are measured at a national level through the Adult Social Care Outcomes Framework (ASCOF). ASCOF measures how well care and support services achieve the outcomes that have been shown by researchers …
Under Consideration
#1 — Adult social care system fails to meet needs and lacks robust data for effective reform.
Recommendation: The current adult social care system does not sufficiently meet the needs of the population despite the efforts of millions of paid and unpaid carers. Financial pressures mean that those needing care sometimes only receive basic support, far from enough …
Gov response: We recognise that people face challenges in accessing adult social care, with many going without the care they need or grappling with a complicated system. Lord Darzi’s report highlighted a growing gap between requests for …
Accepted
#25 — Support neighbourhood pilot sites to address digital interoperability challenges and share best practice.
Recommendation: In order for the neighbourhood pilots to realise the potential of the innovative model of care they are trialling, the Government should support the pilot sites to address challenges with digital interoperability, for example through sharing of learning and best …
No Published Response
#25 — Simplify data sharing guidance with Integrated Care Systems to improve provider collaboration.
Recommendation: We recommend that the Department of Health and Social Care work with Integrated Care Systems to simplify data sharing guidance to improve data sharing between providers. (Recommendation, Paragraph 124)
Response Pending
#24 — Concerns about data sharing legislation act as a barrier to effective partnership.
Recommendation: Throughout this inquiry we heard that concerns about the legislation around data sharing was acting as a barrier to partners working effectively together. While some local areas have developed their own systems to support effective data sharing, stakeholders were clear …
Response Pending
#23 — Produce plans for disaggregated children's outcome data and introduce separate waiting time reports for under-twos.
Recommendation: We recommend that the Government work with all NHS and early-years settings to produce plans for greater disaggregated data concerning service delivery and outcomes for children. This should include data broken down by age group, as well as ethnicity, disability, …
Response Pending
#22 — Government lacks essential data on children's health outcomes in first 1000 days.
Recommendation: The Government does not have access the data it needs on children’s health outcomes during the first 1000 days. Without this data it will struggle to deliver meaningful improvements or implement a shared outcomes framework. (Conclusion, Paragraph 116)
Response Pending
#21 — Single Unique Identifier pilots demonstrate potential for simplifying early years data sharing.
Recommendation: The introduction of a Single Unique Identifier has the potential to significantly simplify data sharing across the early years landscape and we hope that currently planned pilots proceed smoothly and at pace. We ask that the Government commit to providing …
Response Pending
#17 —
Recommendation: Given the UK’s strengths in statistical analysis and data science, it is regrettable that poor data flows, delays in data-sharing agreements and a general lack of structuring and data integration across both the health and social care sectors have throttled …
Gov response: GCSA and CMO have, since the start of the pandemic, engaged with international counterparts on a regular basis in order to share information during what has been a rapidly evolving situation. The UK is currently …
Under Consideration
#23 —
Recommendation: The Department of Health and Social Care, with support from UKSA, should undertake an urgent review of health data systems in England. The review should include consideration of the role of the Department of Health and Social Care in bringing …
Gov response: We agree that cross-organisational working is more important than ever given the large number of organisations across health and social care and the nature and impact of COVID-19. As a result of the Government’s actions …
Not Addressed
#9 —
Recommendation: There is huge potential in NHS cancer data, and a large amount of data from NHS cancer services is already collected and reported. However, there is significant room for improvement, particularly in reducing the two years it takes to collect …
Gov response: The Government welcomes the Committee’s recognition of the work that is already under way to deliver on the ambition to diagnose 75% of cancers by 2028. The NHS Cancer Programme is focused around six priorities …
Under Consideration
#12 —
Recommendation: We urge the department to mandate ICBs to maintain a fully populated palliative and end of life care dashboard that is actively used for commissioning, service planning, quality improvement, and inequality monitoring across their local system. (Recommendation, Paragraph 52)
Response Pending
CQC Inspection Actions (9)
Westhaven
The provider must ensure decision specific mental capacity assessments are completed for people who might lack the capacity to make decisions about their care.
Must Do
Cygnet Bury Hudson
The service should ensure that it continues to improve the electronic care records system to include Mental Health Act and Mental Capacity Act paperwork to avoid confusion and duplication.
Should Do
Cary Lodge
Consent was not always sought from people before care and treatment was provided. 11(1)
Must Do
Wrottesley House
The provider must ensure they are consistently applying the requirements of the Mental Capacity Act 2005.
Must Do
Westhaven
The provider should consult and implement good practice in relation to consent and mental capacity assessments.
Should Do
Woodlands
Consent to care and treatment was not always sought in line with the Mental Capacity Act 2005.
Must Do
The Homestead (Crowthorne) Limited
The registered provider failed to ensure the service was working within the MCA legal framework.
Must Do
Gledhow Lodge
We recommend the registered manager and staff review MCA assessments in line with best practice guidelines.
Should Do
Melville House
The provider must ensure the requirements of the Mental Capacity Act 2005 (MCA) are being met.
Must Do
HMICFRS Recommendations (3)
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, where required, chief constables should seek changes to their crime recording systems to enable staff and officers to document and search for crimes not recorded as the principal crime, with stalking and related offences fully searchable.
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, the Home Office should work with the College of Policing, the NPCC lead for stalking and harassment and the National Stalking Consortium to update information on stalking, aligning crime recording rules with Stalking Protection Act guidance.
Recommendation
Police perpetrated domestic abuse: Report on the Centre for Women's Justice super-complaint
To improve the consistent recording and monitoring of PPDA cases, the Home Office should amend the Annual Data Requirement connected to misconduct cases and criminal investigations. Police forces should be required to report the number of misconduct cases and criminal …
Recommendation
NAO Audit Recommendations (12)
Protecting and supporting the clinically extremely vulnerable during lockdown
DHSC should set out the core data requirements it is likely to need in a future pandemic or civil emergency and how it can access these data in a timely manner;
Accepted
Protecting and supporting the clinically extremely vulnerable during lockdown
DHSC should ensure that healthcare data systems allow easy, but secure, access to healthcare data;
Accepted
Progress in preventing cardiovascular disease
DHSC and NHSE should assess the effectiveness of data flows between DHSC, local authorities and primary care to inform a data improvement programme. This should include an assessment of the feasibility of adding Health Check data to CVDPREVENT and of …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 16: NHSE analysts should document and share their long-term assumptions, for each iteration of the LTWP, within NHSE and with HM Treasury and DHSC. NHSE analysts across the organisation should use common assumptions where possible.
Accepted
Active Travel in England
In establishing itself as a new executive agency, ATE should: e. develop a clear, consistent framework for standardised local data collection to provide baselines and inform scheme evaluations using comparative analysis. This plan should draw on digital technologies and ATE …
Accepted
Progress in improving mental health services in England
d) NHSE, working with ICBs, should develop and issue guidance in 2023 on how the system will gain more transparency over capacity, activity, performance and outcomes in community mental health services, including improvements required to implement the proposed new clinical …
Accepted
Improving family court services for children
MoJ, DfE, HMCTS and Cafcass, working through the FJB, should agree a data and evidence strategy to identify data gaps from a family justice whole system perspective and consider how it will address these. This should include examining data in …
Accepted
Improving family court services for children
MoJ, DfE, HMCTS and Cafcass, working through the FJB, should agree a data and evidence strategy to identify data gaps from a family justice whole system perspective and consider how it will address these. This should include examining data in …
Accepted
Improving family court services for children
MoJ, DfE, HMCTS and Cafcass, working through the FJB, should agree a data and evidence strategy to identify data gaps from a family justice whole system perspective and consider how it will address these. This should include examining data in …
Accepted
Reducing the backlog in criminal courts
• strengthening its work with the judiciary and regional offices to capture local intelligence systematically and consistently.
Accepted
Reducing the backlog in criminal courts
d) support improvements in data it needs for recovery by: • devising and implementing a plan to tackle the systemic barriers to collecting, using and sharing data effectively across the criminal justice system; and
Accepted
Challenges in using data across government
c) Develop cross-government rules, standards and common ways to collect, store, record and manage data. Where multiple standards are used, government should develop a consistent approach to balancing competing demands between standardisation and local requirements, including implications for future decision-making …
Accepted
IMB Annual Reports (2)
Erlestoke (2022)
The report covers HMP Erlestoke from April 2021 to March 2022, a period significantly impacted by Covid-19 restrictions that limited out-of-cell time. Despite challenges like staff shortages and high turnover, the Board found prisoners to be relatively safe, though violence increased and self-harm remained high. Key concerns include delays in transfers, inadequate mental health provision, and the slow pace of infrastructure improvements.
PRISON
Key concerns
Hewell Grange (2020)
This report covers the final six months of HMP Hewell Grange as it underwent a planned closure, ceasing to hold prisoners by 31 March 2020. The Board found the prison generally safe and praised staff for their humane management of the closure, despite unacceptable living conditions. Healthcare provision was inconsistent, and purposeful activity was curtailed due to the closure, though efforts were made to minimise negative impacts on resettlement.
PRISON
Key concerns
IMB Recommendations (11)
Gartree (2024)
The Minister has previously advised that healthcare provision is monitored and reviewed by NHS England Midlands Clinical and Quality Team. Despite numerous requests by the Board, the healthcare provider has steadfastly declined to provide any meaningful quantitative data for monitoring the healthcare provision and benchmark against the community equivalent. Again, we ask the Minister to explain how the Ministry of …
Ministry of Justice
Erlestoke (2021)
Will steps be taken to enhance IT capabilities in this regard?
NHS / Healthcare Provider
Wakefield (2022)
The ACCT ‘system’ remains wholly paper based. This means that ACCT data produced by staff and IMB members in the form of contemporaneous notes and entries into a prisoner's ACCT file are disaggregated from healthcare data contained in NHS SystmOne and operational data in HMPPS Digital Prison Services (formerly C-NOMIS). This inhibits information sharing between prison officers, governors, registered nurses …
HMPPS
Guys Marsh (2021)
HMPPS should prioritize investing in more efficient IT systems to improve both staff efficiency and accurate, timely communication.
HMPPS
Gartree (2021)
Will the Prison Service work with the Board to ensure that it has access to necessary information, for example healthcare data, so that the Board is able to monitor more effectively how well the prison is meeting the standards and requirements placed on it and what impact these have on those in its custody?
HMPPS
Wakefield (2022)
We repeat our request in the 2020-21 annual report to ask HMPPS to clarify progress on the integration of the SystmOne project led by the Ministry of Justice’s digital team.
HMPPS
Grendon (2022)
Improved governance of healthcare data and outcomes (6.1.2) and overseeing delivery of health champions and improved communication with men (6.1.7).
Governor / Director
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
We would recommend a review with consideration being given to standardisation of the translation devices across all of the facilities.
Home Office
Grendon (2023)
The Board looks forward to a monthly set of routinely collected/agreed healthcare data through which we can monitor the quality of healthcare.
Governor / Director
Foston Hall (2023)
The healthcare service does not collect equalities’ data and, therefore, cannot monitor for disproportionate outcomes. When will this be addressed?
Governor / Director
The Mount (2024)
A proper data recording and management system should be introduced to replace the current use of myriad internally constructed spreadsheets and PowerPoint documents that are isolated, inconsistent and require too much manual involvement when reports or information are called for (see §9).
HMPPS
Detention Investigations (2)
Review into the Welfare in Detention of Vulnerable Persons — Rec 51
I further recommend that an alternative to SystmOne be pursued for those detention facilities not in England.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R41
Healthcare should agree with how cleaning must be improved and how these new standards are adopted and maintained. Healthcare facilities should be deep-cleaned at least twice yearly. (To be completed as a matter of urgency)
Immigration Detention
LGO / SPSO Decisions (7)
PSOW-202407175 — Hywel Dda University Health Board
Mrs X complained that Hywel Dda University Health Board failed to provide regular monitoring of her ophthalmic condition. Mrs X also complained that the Health Board had not responded to her letter to the Consultant and found the follow-up responses to her email to be inadequate. The Ombudsman found that …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407486 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to respond to his complaint that was submitted to it in June 2024. The Ombudsman concluded that whilst the Health Board had issued several holding letters, it had failed to provide a formal complaint response in line with its internal …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407409 — Aneurin Bevan University Health Board
Mr C complained that Aneurin Bevan University Health Board had failed to respond to the complaint he submitted in May 2024. The Ombudsman decided that there had been a significant delay by the Health Board to provide Mr C with a response. She said this had caused frustration and uncertainty …
PSOW (Public Services Om…
Health
Feb 2025
PSOW-202408113 — Cwm Taf Morgannwg University Health Board
Ms M complained that Cwm Taf Morgannwg University Health Board failed to respond to a complaint she raised on 6 June 2024. The Ombudsman found that there had been a significant delay by the Health Board in concluding the complaint. This caused additional frustration and inconvenience for Ms M. She …
PSOW (Public Services Om…
Health
Feb 2025
PSOW-202408229 — NHS Wales Shared Services Partnership
Mr A complained that NHS Wales Shared Services Partnership failed to respond to the complaint he made to it in November 2024 relating to access to GP services. The Ombudsman found that NWSSP had provided a brief initial response signposting Mr A to make a complaint to his local Health …
PSOW (Public Services Om…
Health
Feb 2025
21-004-987 — Birmingham City Council
Summary: The Council is not making consistent decisions about whether housing applicants can bid on properties with one less bedroom than they need. The Council has agreed to take action to ensure its decisions are consistent in future.
LGO (Local Government & …
Housing
Upheld
Apr 2022
21-009-514 — Lancashire County Council
Summary: Ms X complained the Council is failing to meet her eligible care needs, has not properly assessed her financial situation and has given her inconsistent information about her care costs. The Council has failed to show how Ms X’s eligible needs are met through her support plan and has …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022