Major project lessons learned
Repeated failure to effectively apply lessons learned from past major projects, leading to recurring mistakes in cost and schedule management.
1,123 items
11 sources
16 inquiries
Source spread
Where this theme appears
Major project lessons learned has been flagged across 11 independent accountability sources:
49 inquiry recs
62 PFD reports
559 committee recs
2 CQC actions
7 ICIBI recs
1 PPO rec
393 NAO recs
15 IMB reports
32 IMB recs
2 detention investigation recs
1 LGO/SPSO decision
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 (49)
POH-16 — Clarify whether HCRS and OCS assessment processes differ
Recommendation: The Department shall make a public announcement in which (a) it clarifies whether there will be any differences in the process for assessing financial redress, between the merged HCRS and OCS, and the process currently operating in OCS and if …
Gov response: Department for Business and Trade accepts this recommendation. DBT confirms that HCRS applies identical principles to the previous OCS scheme, ensuring no disadvantage to overturned conviction claimants. Case management and independent panel processes are in …
Accepted
MAI-155 — Obtain comprehensive accounts from commanders
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should take steps to ensure that all emergency services understand the importance of promptly obtaining comprehensive accounts from commanders as part of 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-128 — National systems to record lessons from exercises
Recommendation: The Ministry of Housing, Communities and Local Government should ensure that there exist robust national and local systems to identify and record the lessons learned from all multi-agency exercises and ensure that change is implemented as a result, where change …
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-127 — Robust debrief systems for multi-agency exercises
Recommendation: The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems and sufficient resources to make sure that the debrief process following multi-agency exercises is effective to capture 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
MAI-62 — LRF oversight of lessons from exercises and incidents
Recommendation: Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those …
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-26 — Review international practice on medics with firearms officers
Recommendation: Counter Terrorism Policing Headquarters should review the experience of other jurisdictions that embed medics with police firearms officers, such as Recherche, Assistance, Intervention, Dissuasion (RAID) in France, to understand how their systems operate and whether they ought to be replicated …
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-18 — Address BTP systemic failings from Volume 1
Recommendation: BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
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
5 — Require proper cell sharing risk assessments
Recommendation: The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least …
Gov response: A new staffing model delivers a healthier ratio of custodial staff per detained individual. The Home Office states that cell sharing risk assessments are covered under the new contractual arrangements.
Accepted in Part
FLIX-209 (iii) — Extend steam boiler modification regulations to hazardous material pressure systems
Recommendation: That existing regulations relating to modifications of steam boilers which do not apply to pressure systems containing hazardous materials should be extended so as to apply to such systems. In framing such regulations consideration will no doubt be given to …
Unknown
FLIX-209 (ii) — Inspect and test modified hazardous pressure systems by competent persons
Recommendation: That all pressure systems containing hazardous materials should be subject to inspection and test by a person recognised by the appropriate authority as competent after any significant modification has been carried out and before the system is again brought into …
Unknown
FLIX-209 (i) — Ensure plant modifications meet original design, construction, testing standards
Recommendation: That any modifications should be designed, constructed, tested and maintained to the same standards as the original plant.
Unknown
SHI-10 — Uniform policy for obtaining technical advice
Recommendation: This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it is not clear from the available evidence that any such …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
SHI-7 — Independent validation of hospital construction
Recommendation: It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility that the facility's specialised ventilation systems have been independently validated by an Authorising Engineer as fit for purpose …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: For any future revenue-funded project
Accepted
In progress
SHI-6 — Information on common construction errors
Recommendation: It is important that common project errors are not repeated. One helpful step is to ensure health boards undertaking projects have information about such common errors, and that this information is clearly communicated to them. This would ensure that health …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: NHS Scotland Assure is developing a framework of training and lessons learned that will be accessible …
Accepted
In progress
SHI-5 — Streamlining NHS construction quality procedures
Recommendation: A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment Process ("NDAP"). There is also a Sustainable Design and Construction Procedure ("SDAC"). In addition, there is the NHS …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025 (GIQ S6W-40544): NHS Scotland Assure has implemented a Key Stage Assurance Review (KSAR) process; specifications of …
Accepted
In progress
BAHA-46 — Lessons Learned Process
Recommendation: The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and …
Gov response: Accepted. Lessons learned processes have been improved for faster dissemination.
Accepted
FENN-59 — Establish a managed safety programme to implement inquiry recommendations
Recommendation: London Underground must establish a managed safety programme under the control of the Director and Company Secretary initially to implement the recommendations in this Report. In time it should be extended to cover other activities.
Unknown
HIDD-46 — Fully implement Automatic Train Protection within five years, prioritising busy lines
Recommendation: The Court welcomes BR's commitment to introduce Automatic Train Protection on a large percentage of its network, but is concerned at the timetable proposed. After the specific type of ATP system has been selected, ATP shall be fully implemented within …
Unknown
HIDD-41 — Utilise on-train data recorder information for systematic safety monitoring procedures
Recommendation: BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Unknown
HIDD-36 — Continue implementing Total Quality Management Initiative and BS5750 quality systems
Recommendation: BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Unknown
FLIX-224 — Urgently investigate crack propagation and corrosion protection for clad steel vessels
Recommendation: The question of crack propagation and detection in internally clad mild steel vessels and their protection from corrosion on the outside should be investigated as a matter of urgency.
Unknown
FLIX-223 — Review regulations for licensing and storage of highly flammable liquids
Recommendation: We have pointed out in Paragraph 194 (c) above that the present situation regarding the licensing and storage of highly flammable liquids is unsatisfactory. We recommend review of the existing regulations.
Unknown
FLIX-221 — Devise scheme for HSE to advise planning authorities on plant safety
Recommendation: A scheme for co-ordination between the planning authorities and the Health and Safety Executive should be devised so that the planning authorities may be advised on the safety problems involved in any proposed plant before planning permission is granted.
Unknown
FLIX-216 — Install fire and explosion-proof recording devices for vital plant information
Recommendation: It is recommended that consideration be given to installing devices or systems for recording vital plant information in a form which would survive the effects of fire or explosion. An example of such a device is the “black-box” used in …
Unknown
FLIX-214 — Inform industry about rapid creep cavitation fractures in stainless steel
Recommendation: Creep cavitation fractures in stainless steel have been known for some time but previously it had not been generally known that these could, under appropriate conditions of stress and temperature be produced in a relatively short time. Such a fracture …
Unknown
FLIX-213 — Alert industry to risks of zinc-coated components in chemical plants
Recommendation: Since many chemical plants contain zinc coated components, eg galvanised wire and walkways, it is important that the attention of industry should be drawn to these matters.
Unknown
FLIX-212 — Alert industry to nitrate stress corrosion risk from contaminated cooling water
Recommendation: The cracked Reactor R2525 initiated the sequence of events which led to disaster. Examination of the crack by expert metallurgists showed that the crack had been caused by nitrate stress corrosion. This corrosion was created because nitrate treated cooling water …
Unknown
CR18 — MAIB publication of implementation measures
Recommendation: The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom a recommendation is addressed, or an explanation for not taking …
Response Pending
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it, including co-location of representatives from each organisation relevant to the particular stage, enabling issues to be addressed and resolved at the earliest opportunity, minimising risk …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-18 — Effective Communication and Reporting
Recommendation: There should be effective communication and reporting at all stages of the project, including accurate progress reports to councillors and stakeholders, with clear escalation procedures for issues that may affect cost, programme or scope.
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
F126 — Preserving corporate memory
Recommendation: The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as …
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
44 — Establish framework for future investigations
Recommendation: This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were …
Gov response: 69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously …
Accepted
37 — Protocol for organisational change transitions
Recommendation: Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This …
Gov response: 100. We accept this recommendation. We agree that these are important concepts, and indeed a number of protocols were drawn up and widely communicated in managing changes to the health system in 2012. The Department …
Accepted
BAHA-20 — Doctrine Usability Review
Recommendation: The MoD should ensure that Development Concepts and Doctrine Centre (DCDC) reviews whether its protocols for layout and pagination of joint doctrine really serve the end user.
Gov response: Accepted. DCDC has reviewed and improved the layout and accessibility of joint doctrine publications.
Accepted
FENN-58 — Provide separate funds for scientific adviser's research and development
Recommendation: The scientific adviser of London Underground shall be provided with separate funds for research and development.
Unknown
LADB-6 — Improve Railtrack procedures for implementing and monitoring accepted recommendations with clear accountability
Recommendation: Railtrack procedures, and the actions of management to enforce them, should be directed to ensuring that: (i) a recommendation which is accepted is implemented according to a defined timescale; (ii) the person to whom a recommendation is allocated for implementation …
Unknown
LADB-5 — Require holistic safety and risk assessment for all track or signalling changes
Recommendation: Where a material change to track or signalling or both is proposed, there should be an express consideration of all relevant safety issues by an analysis of the material factors, if necessary by means of a risk assessment. This should …
Unknown
CLAR-2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the …
Unknown
CLAR-13.53.2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-13.53.1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the …
Unknown
HIDD-54 — Complete research programme into structural integrity of rolling stock by April 1991
Recommendation: BR shall carry out its stated programme of research into the structural integrity of its rolling stock within its planned timescale of completion by April 1991.
Unknown
HIDD-43 — Prioritise installation of driver-signalman radio communication on all traction units
Recommendation: BR shall implement as a priority its programme to install a system of radio communication between driver and signalman on all traction units. The introduction of this system shall be in addition to signal-post telephones and not automatically entail their …
Unknown
HIDD-40 — Prioritise introduction of on-train data recorders for incident investigation assistance
Recommendation: BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Unknown
P2-58 — Reconsider LGA Guide paragraph 79.11 advice
Recommendation: That the advice contained in paragraph 79.11 of the LGA Guide be reconsidered. (113.83)
Gov response: The government accepts this recommendation. The advice contained in paragraph 79.11 of the LGA Guide was redacted in 2021. The Home Office intends to publish new guidance on the issues covered in paragraph 79.11 in …
Accepted
P2-57 — Reconsider Phase 1 recommendations in light of Phase 2
Recommendation: That further consideration be given to the recommendations made in the Phase 1 report in the light of our findings in this report. (113.82)
Gov response: The government accepts this recommendation. We addressed these recommendations in the response to the Emergency Evacuation Information Sharing Plus (EEIS+) consultation published on 2 December 2024.
Accepted
In progress
P2-9 — Include academics on statutory guidance advisory bodies
Recommendation: That, as far as possible, membership of bodies advising on changes to the statutory guidance should include representatives of the academic community as well as those with practical experience of the industry (including fire engineers) chosen for their experience and …
Gov response: The government accepts this recommendation. We agree that a diverse range of representatives, including those from academic and professional communities, should be included in membership of bodies advising on changes to statutory guidance. The Building …
Accepted
In progress
P2-6 — Add legal requirements warning to statutory guidance
Recommendation: That a revised version of the guidance contain a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them. (113.12)
Gov response: The government accepts this recommendation. We will address this through the response to recommendation 5.
Accepted
In progress
R2 — HMP Maghaberry lessons learned
Recommendation: Many of the problems of HMP Maze in 1997 arose from the fact that by then it was the sole prison in Northern Ireland holding the most dangerous terrorist prisoners. We are aware that HMP Maghaberry is currently the sole …
Gov response: Secretary of State Owen Paterson stated on 14 September 2010 that he would discuss all three recommendations with Justice Minister David Ford, as prisons had become a devolved matter. Some operational lessons from HMP Maze …
Accepted
PFD Reports (62) — showing 50 strongest matches
Dean Griffiths
Concerns: Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
Overdue
Sean Cunningham
Concerns: A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical information.
Overdue
Esther Jones
Concerns: Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Response (NHS England): NHS England is reviewing service specifications, establishing a national expert group for oncology, enhancing reporting to the BSBMT registry, and commissioning its quality surveillance team to assure changes in governance.
Responded
Huseyin Erdogan
Concerns: Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
Overdue
Michael Pollard
Concerns: An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, up-to-date system.
Response (University Hospitals of Leicester NHS Trust): University Hospitals of Leicester NHS Trust's Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the …
Responded
Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
Concerns: The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
Response (Ministry of Defence): The Ministry of Defence is conducting a review of the vehicle suspension system, including data analysis and investigation into alternative bolts. They are also addressing the Vehicle Emergency Lighting System …
Responded
Richard Laco
Concerns: Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to significant workplace safety risks.
Response (Richard Laco Response2): CMF Ltd will ensure lifting operations are planned by a qualified appointed person, use their native lift plan procedure, submit plans to the Principal Contractor for approval, explain plans to …
Response (Richard Laco): Laing O'Rourke issued a Safety Alert requiring sign-off by their Appointed Person for Lifting on all contractor lift plans and requires project teams to review high-risk activities monthly with 'Planned …
Responded
Peter Barnes
Concerns: Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official safeguarding measures, despite clear risks to flight paths.
Response (Peterwood): • The London Heliport has continued its correspondence with both CAA and DfT in order to provide information to progress consideration of official safeguarding of the London Heliport and assist …
Response (Peterwood): • The Flight Operations team is conducting a review of the safety of onshore helicopter operations in the UK this year. • The review will include a post implementation review …
Overdue
Darren Wakefield
Concerns: The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing or verifying crucial safety improvements.
Response (Department for Transport): The Department for Transport has reviewed legislation regarding derelict vessels and concluded that the existing legal framework is sufficient. They have provided further guidance in the revised Port Marine Safety …
Responded
Joseph Sarkozi
Concerns: Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.
Response (Avon Fire PFD): Avon Fire & Rescue will include the incident scenario in training packages for operational crews, notify personnel via the "Fire Alert" system, amend the Domestic and Residential Fires risk card, …
Overdue
Jakovas Fofonovas
Concerns: Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of the inquest.
Response (Network Rail): Network Rail demolished and replaced the footbridge at Bostall Manor Way with a new, safer design, including industry standard height railings (1250mm) and acoustic fencing with anti-climb extensions. Old building …
Responded
Steven Murphy
Concerns: South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing over a footbridge parapet.
Overdue
Nathan Charman
Concerns: The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.
Response (Durham County Council): Durham County Council reviewed the incident and has amended the Winter Maintenance Operational Plan to align gritting route 28 to the Low Pennines weather forecasting domain and to confirm that …
Responded
Gerome Reyes
Concerns: There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on this and potentially other ships.
Overdue
Melanie Lowe
Concerns: The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.
Response: The Trust updated its action plan with supporting evidence and will complete a further audit to ensure that all the actions identified have been embedded into practice.
Responded
Gordon Penistan
Concerns: Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.
Response (ADASS): ADASS circulated a confidential briefing regarding the coroner's report to all 153 local authorities with responsibility for adult social care via their news bulletin.
Responded
Dorothy Breislin
Concerns: There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.
Response (Response United Lincolnshire Hospitals NHS Trust): The Trust is implementing a new SI process which incorporates training across the Trust and a new Risk Manager will start in February 2018. The updated clerking proforma risk assessment …
Responded
Neville Welton
Concerns: The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Response: The Health Board is establishing weekly meetings for senior staff to review incidents, track progress of investigations, and ensure timely action plan implementation, commencing July 12th, 2018. They will also …
Overdue
Alexia Walenkaki
Concerns: Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections due to unclear role demarcation, led to a fatal incident.
Overdue
Evie Wright
Concerns: A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to stalled plans and unclear responsibility, despite acknowledged safety benefits.
Response (Persimmon Homes): Persimmon Homes attended meetings with North Somerset District Council and agreed to attend a further meeting with Network Rail to explore an acceptable resolution, including a significant financial contribution for …
Response (North Somerset Council): North Somerset Council will meet with Persimmon Homes, seek Network Rail's engagement, and consider measures to improve crossing safety. By specific dates, they will seek Network Rail's confirmation of design …
Responded
Clive Jones
Concerns: An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for reliability.
Response (Department for Transport): An independent review of the UK search and rescue (SAR) operational capability and functionality will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. A review …
Responded
Lucia Stear
Concerns: Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.
Response (Local Government Association): The LGA will include an item in its email bulletins to local authority chief executives and environmental officers, will host an online event with relevant officers by the end of …
Response (Ministry of Housing Communities Local Government): The Ministry acknowledges the coroner's concerns and highlights the increase in Core Spending Power for local government and the allocation of funds for park renovations, noting that spending on parks …
Responded
Jean Waghorn
Concerns: There were unnecessary and inappropriate transfers between hospitals, and the Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored, despite previous regulation 28 reports concerning the Transfer Policy.
Overdue
Joshua Hoole
Concerns: A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself is complex and lacks clear protocols for individual risk and new fitness tests.
Response (Ministry of Defence): The Ministry of Defence has taken corrective action following concerns raised regarding the death of Corporal Joshua Hoole, including improved awareness of Joint Service Publication 539, updating the User Guide …
Responded
Malyun Karama
Concerns: There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in delivery suites hinders contemporaneous observation recording.
Response (Royal Free London NHS Foundation Trust): The Royal Free London NHS Foundation Trust has shared learning from the case at the North Central London Local Maternity System Quality and Safety Meeting, communicated with the national maternity …
Responded
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Concerns: The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack of mandatory recording impedes urgent communication and tracing between stakeholders.
Response (MP BEIS): The Department for Business, Energy & Industrial Strategy (BEIS) has asked the Office for Product Safety and Standards (OPSS) to engage with manufacturers, retailers, consumer groups, and government bodies to …
Overdue
Lee Marsden
Concerns: A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of an internal review, indicate a missed opportunity for learning.
Response (National Highways): Highways England will brief North West Highways England Regional Operations Centre staff and police officers on using 'free text' entries in incident logs, shared with all Regional Control Centres as …
Response (North West Motorway Police Group): Highways England and the NWMPG have agreed to add a free text description to the log to clearly identify the source of information. Police operators and supervisors within NWMPG will …
Responded
Vilmantas Venskutonis
Concerns: The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, needs to be confirmed and any partial implementation justified.
Overdue
Christine Gould
Concerns: Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than keeping an open mind about alternative routes.
Response (Network Rail): Network Rail is upgrading the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing and has completed a significant portion of the upgrade. They are also reviewing …
Response (British Transport Police): The British Transport Police has created a single Fatality Investigation Team, trained frontline staff, and implemented procedures for Post Incident Site Visit (PISV) reports. They are working with Network Rail …
Responded
Kyle Hurst
Concerns: The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Response (BCUHB): BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and …
Responded
Susan Merton
Concerns: The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Response (BCUHB): BCUHB changed its serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. The Health Board is tracking …
Overdue
Jonathan Bayliss
Concerns: Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.
Response (Ministry of Defence): The MOD is undertaking investigations into incorporating an artificial stall warning capability in the Hawk T Mk1, with a decision expected in summer 2022. The RAF is developing options for …
Responded
Gregory Barber
Concerns: Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.
Response (Network Rail): Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind a parapet wall and will close off gaps at either end of the new fence, with …
Responded
Glendys Roberts
Concerns: Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, vascular emergency pathways, and an ambulance handover plan has been unacceptably slow.
Response (Betsi Cadwaladr University Health Board): Betsi Cadwaladr University Health Board is reviewing intra-hospital transfer processes with support from the National Collaborative Commissioning Unit and modeling service demand. They are also working with WAST on ambulance …
Response (Welsh Ambulance Service NHS Trust): The Trust is working with Betsi Cadwaladr University Health Board and the National Collaborative Commissioning Unit to improve intra-hospital transfer resources, including developing a proposal for dedicated transfer resources, and …
Responded
John Abrahams
Concerns: Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including attempted suicide.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA convened the Isotretinoin Expert Working Group (IEWG) to evaluate data on risks associated with isotretinoin and the Implementation Working Group has had two meetings in March 2023 and …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA published a report on isotretinoin's side effects and issued a Drug Safety Update. An Implementation Working Group is developing recommendations for safe introduction of new measures, with outputs …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns regarding Isotretinoin and refers to the MHRA's response; they note that the Isotretinoin Implementation Working Group has met and is drafting …
Responded
Raniya Khan
Concerns: The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.
Response (Royal Berkshire NHS Foundation Trust): The Trust has implemented a process for storing placentas for 48 hours for histological examination, detailed in SOP MATSOP064, and has also strengthened the Policy for feedback of concerns raised …
Response (Essex Partnership University NHS Foundation Trust): The Trust has updated psychotherapy discharge letters to include prompts for discharge planning, requires written communication with the locality MDT team prior to the discharge of patients on Section 117 …
Responded
Ben Harrison
Concerns: The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in implementing action plans following a death, risking recurrence of similar incidents.
Overdue
Thomas Jayamaha
Concerns: Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.
Response (Nottinghamshire Healthcare NHS Foundation Trust): The Trust and ICB have developed an action plan for implementing the autism strategy, including flagging, reasonable adjustments, peer support, care planning, and workforce development. A clinician-led triage assessment is …
Responded
Jodie McCann
Concerns: Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also delayed crucial organizational learning.
Response (University Hospitals of Derby and Burton NHS Foundation Trust): The Intensive Care Unit at Queens Hospital Burton introduced a Critical Care Airway Plan, anaesthetic consultants provided airway management training, and an updated Incident Reporting Policy will include presentations and …
Responded
Nancy Price
Concerns: The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.
Response (Betsi Cadwaladr University Health Board): The Health Board is re-evaluating the incident process with a new procedure document to be developed by the end of August 2023, addressing overdue investigations with weekly meetings, and implementing …
Responded
Christine Cumbers
Concerns: The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future reoccurrences.
Response (Ranworth Medical Group): Ranworth Medical Group addressed the consultation concern with the individual clinician and disseminated learning at a practice meeting on 9/8/22 in an anonymous manner. They completed an audit of consultations …
Responded
Leah Barber
Concerns: Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
Response (City of Bradford Metropolitan District Council): Following the death, the Council has strengthened processes to ensure organizational oversight where multiple teams are involved and a child dies, with the Director of Children’s Services as the single …
Responded
Paula Lenihan
Concerns: The report identifies a pattern within the Birmingham & Solihull Mental Health NHS Foundation Trust of risk assessments not being completed or updated as expected, which poses a risk due to insufficient risk recording; a task and finish group is addressing the issue, but it is at an early stage.
Response (Birmingham and Solihull Mental Health): Birmingham and Solihull Mental Health Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation, set up a project group to look …
Responded
Sarah Holmes
Concerns: The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.
Response (Independent Office for Police Conduct): The IOPC expresses condolences and explains its role in the police complaints system. It details the recommendations made to Durham Constabulary, their response, and the IOPC's follow-up actions to seek …
Response (Department for Work and Pensions): DWP expresses condolences and states that existing guidance and support are adequate for vulnerable customers. They describe the call-back procedure followed and note that the ESA agent did not stop …
Response (Tees Esk and Wear Valleys): TEWV acknowledges concerns and details actions taken including confirming assessment methods, developing an interim policy to address disputes between police and mental health services, and preparing a patient safety briefing …
Response (Durham Constabulary): The Police and Crime Commissioner acknowledges receipt of the report and expresses condolences. They state they have discussed the concerns with the Chief Constable, who has implemented an interim escalation …
Response (Police): The constabulary has worked with TEWV to develop a strong partnership plan, implemented an interim escalation policy, and will train frontline officers with a national training package and local guidance.
Responded
Michael Pender, Jan Klempar and Paul Mullen
Concerns: Government policies on lifeguard furlough and lack of advance notice for lockdown relaxation severely hampered RNLI's ability to staff beaches, contributing to drownings due to unpatrolled coastlines.
Response (Cabinet Office): The Cabinet Office has shared concerns about RNLI lifeguard furlough eligibility with HMT and HMRC and refers the overall Covid-19 measures to the UK Covid-19 Inquiry. The MCA works with …
Responded
Thomas Loxton
Concerns: Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical safety recommendations remain outstanding or delayed.
Response (Dudley Integrated Health and Care NHS Trust): Dudley Integrated Health and Care NHS Trust has implemented a more enhanced process for notifying internal and external stakeholders when a patient has died. They are also ensuring these changes …
Response (Black Country Healthcare): Black Country Healthcare has completed a review of the action plan presented at inquest, providing further insight into the completion of all areas of learning identified as a result of …
Responded
Anne Rowland
Concerns: Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of complications.
Response (Surrey and Sussex Healthcare): Surrey & Sussex Healthcare NHS Trust outlines actions taken to improve timely surgery for fractured neck of femur patients including infrastructure improvements and process changes, resulting in improved surgery rates …
Responded
Nancy Rogers
Concerns: The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection presentations.
Response (Morecambe Bay NHSFT): University Hospitals of Morecambe Bay NHS Foundation Trust has displayed posters in the Emergency Department and triage areas, and they are drawing attention to a relevant video at staff meetings. …
Responded
Joseph Parker
Concerns: Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with previous PFD reports on unrecognised oesophageal intubation failing to prompt necessary changes.
Response (NHS England): NHS England acknowledges concerns about oesophageal intubation and the PUMA guidelines and states they will clarify the future direction of the Never Events Framework. They also note that all PFD …
Response (Association of Anaesthetists RCOA and Faculty of Intensive Care Medicine Joint Respons): The organisations agree with the coroner's concerns and highlight their existing work, including the 'no trace = wrong place' campaign, endorsement of PUMA guidelines, and emphasis on capnography in anaesthesia …
Response (Royal College of Emergency Medicine): The RCEM expresses support for adequate staffing, multidisciplinary simulation training, equipment standardization, intubation checklists, and capnography use, referencing an existing framework for collaboration between Emergency Medicine and Intensive Care Medicine.
Responded
Committee Recommendations (559) — showing 50 strongest matches
#5 —
Recommendation: The Department has still not demonstrated that it is embedding lessons learned into its major programmes. This Committee has examined many major transport programmes, such as HS2, Great Western route modernisation and Thameslink, many of which have had significant problems …
Gov response: 5.2 The department is at the forefront of work across government to develop a lessons management approach in conjunction with its delivery partners following the 2019 ‘Lessons from Transport for the Sponsorship of Major Projects’ …
Not Addressed
#25 —
Recommendation: We were concerned that the Department should have identified these lessons when it supported businesses in the 2008 Financial Crisis. In 2010, the NAO’s report on the Department’s support to business during a recession concluded that the “impact [of the …
Gov response: 7: PAC conclusion: The Department has not yet identified how it will share the lessons from the Scheme. 7a: PAC recommendation: The Department and The Bank should establish a strategy on how it intends to …
Accepted
#6 — Outline plans for embedding cross-government learning in future major projects.
Recommendation: Government departments do not routinely learn lessons from their own projects or those of other departments, so are missing opportunities to improve effectiveness and efficiency of future projects. Applying learning about what has been successful in major project delivery can …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The government has committed to regularly reviewing progress against the Industrial Strategy. As above, implementation is a government-wide effort, underpinned by shared objectives and metrics. This …
Not Addressed
#3 — Demonstrate DIO has learned crucial lessons from contract delivery failures.
Recommendation: The DIO must prove it has learned lessons from the failures in the delivery of these contracts. (Recommendation, Paragraph 36)
Gov response: The MOD accepts recommendations 2 and 3. The Defence Infrastructure Organisation (DIO) continues to drive for both improved performance and increased value for money from the Future Defence Infrastructure Services (FDIS) Accommodation Industry Partners (IPs). …
Accepted
#15 — GCAP must break the mould of previous multilateral defence programme failures.
Recommendation: Whilst progress to date has been positive, previous multilateral defence programmes have frequently seen costs spiral and delays pile up and GCAP will have to break the mould if it is to achieve its ambitious target date. Decisions made at …
Gov response: We are grateful to the Committee for its report and the conclusions and recommendations within. GCAP has been designed from the outset to learn lessons from previous programmes, to deliver one of Defence’s most important …
Under Consideration
#12 — Failure to capitalise on Hawk success led to loss of UK manufacturing capacity.
Recommendation: The Hawk trainer aircraft has been a UK defence export success story, but with domestic production lines closing four years ago the skills and manufacturing capacity which had built up over decades will prove challenging and costly to regenerate. We …
Gov response: The Programme of Record for Hawk T2 was for an out of service date (OSD) of 2040, which allowed for time potentially to design and build a follow- on successor for Hawk in the Advanced …
Under Consideration
#4 — Sustain empowerment of Global Combat Air Programme delivery structures to ensure timely decision-making
Recommendation: Given the ambitious timescales for GCAP, its delivery structures at the Governmental and industrial levels will need to be sufficiently empowered to take timely and binding decisions as the programme progresses. A repeat of the structural failings which contributed to …
Gov response: The Department and our international partners have actively learned from previous programmes and agree that an empowered joint delivery organisation will be essential to the successful and timely delivery of the programme. The Treaty underpinning …
Accepted
#24 — Home Office failed to apply lessons from failed asylum sites, incurring significant financial losses.
Recommendation: The second of the IPA reviews, in February 2023, concluded that, while the Home Office had identified learning in relation to the failed site at Linton- on-Ouse, these lessons were not being applied to some of the asylum accommodation sites …
Under Consideration
#5 — Detail lessons from large asylum accommodation site acquisitions and explain process changes to prevent recurrence.
Recommendation: We are not convinced that the Home Office has learned the lessons it identified from its costly acquisitions of large sites. The Home Office claims it has identified “over 1,000” lessons from its acquisition of large asylum accommodation sites. It …
Under Consideration
#48 — HS2 Euston exemplifies department's failure to learn from past major rail projects
Recommendation: The previous Public Accounts Committee also concluded in its 2023 report on HS2 Euston that it was another example of the Department making the same mistakes and failing to learn lessons from its management of other major rail programmes, highlighting …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Summer 2025 The department is committed to learning lessons on the programme and has worked closely with HM Treasury and the National Infrastructure and Service …
Not Addressed
#47 — Department and HS2 Ltd repeatedly fail to embed crucial lessons from major projects
Recommendation: However, the Committee has needed to recommend repeatedly that the Department and HS2 Ltd improve the degree they reflect on past or current experiences and implement any lessons. In 2020, the previous Committee made clear its dissatisfaction: 80 “Given the …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Summer 2025 The department is committed to learning lessons on the programme and has worked closely with HM Treasury and the National Infrastructure and Service …
Not Addressed
#33 — Department defends new Euston delivery body necessity due to project complexity and private investment.
Recommendation: We challenged the Department over the necessity and added risk of establishing an additional delivery body to oversee the works at Euston and its surroundings. The Department recognised that setting up new organisations is far more complex and difficult than …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2025 6.2 The department’s next six-monthly update to Parliament is expected to be published in Summer 2025 and will include an update on …
Not Addressed
#28 — Ensure Department and HS2 Ltd secure necessary skills for successful programme delivery.
Recommendation: The Public Accounts Committee has repeatedly raised concerns over whether the Department and HS2 Ltd have had the necessary skills and capability to deliver HS2 successfully. In 2020 the previous Committee cautioned that it was not yet convinced that the …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: December 2026 5.2 The new CEO of HS2 Ltd started in post in December 2024. He has commenced, as part of the reset, a …
Accepted
#17 — Previous Public Accounts Committee warned HS2 Ltd about managing revised contracts and cost risks.
Recommendation: However, the previous Public Accounts Committee was clear on the risk of these changes and that HS2 Ltd needed to closely manage these contracts. In its May 2020 report it warned that: “Now that it is bearing more of the …
Gov response: 3.1 The government disagrees with the Committee’s recommendation. 3.2 The department agrees with the substance of the recommendation but will require more time before it can update the Committee. HS2 Ltd has concluded the first …
Not Addressed
#8 — Require the Department to report on lessons learned and their practical implementation to the Committee.
Recommendation: Over the last decade the Department and HS2 Ltd have repeatedly said they are learning lessons but there is little evidence that lessons have been applied effectively and mistakes avoided. Since 2013, the Department and HS2 Ltd have told the …
Gov response: The government agrees with the Committee’s recommendation. closely with HM Treasury and the National Infrastructure and Service Transformation Authority to identify key lessons from the programme and how those can be applied. Over the course …
Accepted
#7 — Slow progress on HS2 land and property disposal decisions post-Phase 2 cancellation
Recommendation: Things are moving too slowly on making decisions on the disposal of land and property purchased as part of the programme. The Department has yet to determine what land and property can be disposed of following the cancellation of Phase …
Gov response: The government agrees with the Committee’s recommendation. of these preparations, the department is undertaking a review of the portfolio of land that was previously acquired for Phase 2. This includes the identification of properties subject …
Accepted
#5 — Address HS2 leadership and capability gaps to ensure successful programme delivery
Recommendation: The Department and HS2 Ltd do not have the skills and capabilities needed to successfully deliver the programme. The Public Accounts Committee has repeatedly raised concerns over the Department and HS2 Ltd having the skills and capability they need. Following …
Gov response: The government agrees with the Committee’s recommendation. part of the reset, a comprehensive change programme to reshape the organisation so that it has the skills and capabilities needed to deliver HS2. The reset programme is …
Accepted
#3 — Report progress on HS2 contract renegotiations and plans for achieving cost savings
Recommendation: HS2 Ltd’s construction contracts are unacceptable to the public purse and it is imperative that HS2 Ltd deliver on its assurances to us that it can renegotiate these and deliver significant cost savings. The terms and operation of these contracts …
Gov response: The government disagrees with the Committee’s recommendation. The department agrees with the substance of the recommendation but will require more time before it can update the Committee. HS2 Ltd has concluded the first phase of …
Not Accepted
#18 — Government policymaking and implementation for tax incentives is too slow for global competitiveness
Recommendation: The Government is right to commit to maintaining the competitiveness of the UK’s tax incentives, and changes must be balanced with stability. Yet the production sector is much more agile than Government, and the time it took to reform expenditure …
Gov response: The government has shown its commitment to keeping the UK’s Audio-Visual Expenditure Credit (AVEC) competitive by providing additional support for independent films at a rate of 53% and introducing a 5% uplift in relief for …
Accepted
#4 — Map critical path for BECCS deployment and develop contingency plans for decarbonisation goals.
Recommendation: The deployment of BECCS has been repeatedly delayed, even though it remains a key part of the government’s plans to decarbonise the UK. The Climate Change Committee (CCC) and DESNZ both see BECCS as essential to the UK achieving its …
Gov response: The government agrees with the Committee’s recommendation. effective pathway to meeting the UK’s climate change targets. Greenhouse Gas Removal technologies (GGRs) like BECCS can support net zero targets by delivering negative carbon emissions and producing …
Accepted
#20 — Significant financial waste on previous projects indicates slow learning of lessons at Sellafield.
Recommendation: The previous Committee criticised the NDA in 2018 for failing to learn the lessons from projects it had cancelled after belatedly realising that there were more cost–effective ways to reduce risk (having spent £586 million of taxpayers’ money on three …
Gov response: 3.5 A target focused on improving project and contract delivery by sharing and implementing lessons learned was successfully delivered in 2024-25 and will inform the NDA’s group-wide organisational learning policy.
Accepted
#12 — OGP developing expertise to identify and prevent future property risks from new construction methods.
Recommendation: We questioned whether government is adequately prepared to prevent future risks, similar to the sudden emergence of RAAC and asbestos, from affecting property unexpectedly. The OGP stated that it has a clear picture of RAAC and asbestos across all of …
Gov response: 2. PAC conclusion: The poor condition of some property and the failure to maintain it is regularly affecting the provision of key public services.
Not Addressed
#11 — Addressing RAAC risks in government estates diverted resources from other civil service initiatives.
Recommendation: The NAO reported that civil service resources for other initiatives have been diverted to deal with risks relating to reinforced autoclaved aerated concrete (RAAC) across government.18 We asked the Cabinet Office about RAAC and how it has impacted the delivery …
Gov response: 2. PAC conclusion: The poor condition of some property and the failure to maintain it is regularly affecting the provision of key public services.
Not Addressed
#19 — New procurement approach seeks to prevent over-specification and increase defence exports.
Recommendation: The Department has set the five-year target for programme length to stop the armed forces over-specifying their requirements.34 It said that the troubled Ajax programme, for example, had been tremendously over-specified.35 The Department anticipates it can achieve this target by …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: June 2026 3.2 The department’s procurement reforms are building on previous initiatives and will go further. Teams delivering the national ‘arsenal’, the defence industrial …
Accepted
#3 — Provide Committee by June 2026 with evidence on defence procurement improvements and KPIs.
Recommendation: The Department’s defence reform programme sets out ambitious plans for improving defence procurement, but it is unclear how long it will take for these benefits to become fully embedded. In April 2025 the Department reorganised itself into four areas–the Department …
Gov response: The government agrees with the Committee’s recommendation. further. Teams delivering the national ‘arsenal’, the defence industrial strategy and end to end acquisition have been brought together as the National Armaments Director (NAD) Group, to enable …
Accepted
#2 — Update Committee by June 2026 on operational improvements identified from Ukraine support.
Recommendation: Lessons learned from supporting Ukraine have made the Department examine its own decision-making and procurement processes, finding some of them in need of improvement. The Department has learned several lessons from its support for Ukraine. These include: the need for …
Gov response: The government agrees with the Committee’s recommendation. lessons learned from supplying Ukraine into how it is reforming the department’s procurement processes, and the department is committed to continuing to learn from this conflict. The conflict …
Accepted
#13 — Significant proportion of major government projects still lack an evaluation plan
Recommendation: The Treasury told us that the proportion of major projects that have been evaluated has improved since the NAO’s evaluation report. After our evidence session, the Treasury wrote to us and stated that 68% of infrastructure and construction of major …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 The government’s 10 Year Infrastructure Strategy sets out several of the main basic models available to deploy private finance into projects, many of which …
Not Addressed
#12 — Government activity and private financing models lack robust evaluation frameworks
Recommendation: The National Audit Office’s (NAO) report on evaluating government spending highlighted that much of government’s activity is either not evaluated robustly or not evaluated at all, despite the government’s commitment to evidence-based decision-making.22 In addition, there 17 C&AG’s Report, para …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 The government’s 10 Year Infrastructure Strategy sets out several of the main basic models available to deploy private finance into projects, many of which …
Not Addressed
#11 — Government does not routinely evaluate completed infrastructure projects to assess their success
Recommendation: Though government attempts to determine the success of a project through measures such as cost-benefit analysis, they do not routinely evaluate completed projects.19 The UK has used a variety of private financing models to deliver new infrastructure, including but not …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 The government’s 10 Year Infrastructure Strategy sets out several of the main basic models available to deploy private finance into projects, many of which …
Not Addressed
#29 — Rollout of the Pathfinder model for private law remains significantly slow
Recommendation: MoJ told us that progress with improving timeliness for private law, including in London, will depend on the speed with which it rolls out the Pathfinder model.72 However, despite positive evaluations, wide stakeholder support, and the potential to improve timeliness, …
Gov response: MoJ told us that progress with improving timeliness for private law, including in London, will depend on the speed with which it rolls out the Pathfinder model. However, despite positive evaluations, wide stakeholder support, and …
No Published Response
#4 — Require Defra to assess intentional non-compliance within the BTOM and outline corrective steps.
Recommendation: In the review proposed above, Defra should work with relevant Government departments and non-departmental delivery partners to assess the scale and nature of intentional non-compliance and outline the steps it will take to address this. These lessons should also be …
Gov response: The primary method of intentional non-compliance in relation to SPS imports which is currently known was addressed by the Committee in the report Britain’s illegal meat crisis, published on 8 September 2025. The response to …
Not Accepted
#3 — Department failed to learn from cuts to peacebuilding programming, risking escalating conflict.
Recommendation: The Department has failed to learn the lessons from previous cuts to stabilisation, peacebuilding and deconfliction programming, which likely contributed to the escalation of conflict in Sudan going unchallenged. We are concerned that the recent cuts to the Integrated Security …
Gov response: 9. The alleviation of poverty is the primary purpose of all FCDO Official Development Assistance (ODA) programmes. 10. In light of pressing security challenges, the government has made the necessary decision to reduce the ODA …
Under Consideration
#30 — No formal forum exists for sharing best practice with devolved administrations
Recommendation: We asked the Department whether there were mechanisms to share best practice on themes that are common across other parts of the UK. It explained that fairly regular conversations take place with counterparts in the devolved administrations, but there is …
Gov response: 7. PAC conclusion: The Department does not facilitate effective communication or the sharing of best practice between stakeholders. 7. PAC recommendation: In its Treasury Minute response, the Department should provide the Committee with further details …
Accepted
#7 — Sponsor effective communication among departments, local bodies, and devolved nations to share best practice.
Recommendation: The Department does not facilitate effective communication or the sharing of best practice between stakeholders. Given that developer contributions help to fund a wide range of infrastructure such as schools, health facilities and roads, other government departments have a clear …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The department recognises the importance of effective engagement across government departments and with diverse stakeholders. The department will look to build upon and extend existing channels …
Accepted
#18 — Establish principles for a just industrial transition drawing on lessons from the Grangemouth case.
Recommendation: In its response to this report, the Government should outline what has been learned from this case and what can be done to ensure that comparable industrial transitions will be better managed in future. Having consulted trade unions and communities …
Gov response: The government agrees with this recommendation. We agree that lessons should be learned from Grangemouth to manage the impacts of industrial transitions on workers and communities. The UK government recognises the economic opportunity that the …
Accepted
#19 — Defence industrial base recommendations remain partially implemented, with effectiveness and progress difficult to assess.
Recommendation: The defence industrial base has been subject to numerous reviews, plans and strategies, all of which have identified recommendations. However, many of those have only been partially implemented. Whilst the Government appears to be committed to solving some of the …
Gov response: We appreciate the Committee’s observation and recognise the importance of implementing the DIS commitments. Not only did the Defence Industrial Strategy include measures to address these intractable issues, but implementation was a key consideration. All …
Accepted
#10 — Publish annual updates on implementation of Strategic Defence Review (SDR) commitments
Recommendation: The Government should set out its plan for implementing the SDR. We recommend that the Government publishes an annual update on its implementation of the SDR commitments. In addition, we will continue to 57 seek regular classified updates on its …
Gov response: Following publication of the SSDR report on 2 June 2025, implementation began straight away. This is priority business, executed through a whole- of-Defence effort and driven through the reformed structures of Defence, with clear lines …
Under Consideration
#14 — Committee reiterates concerns regarding FCDO 2030 programme sequencing and implementation speed.
Recommendation: We reiterate our previous concerns around the sequencing and speed of the FCDO 2030 programme. (Conclusion, Paragraph 32)
Gov response: Partially agree (Recommendation 3) Disagree (Recommendation 6) Disagree (Recommendation 7) 15. The FCDO is committed to ensuring that it has the development capability and technical expertise needed to deliver this government’s ambition on development, even …
No Published Response
#35 — Publish compensation position for unused border infrastructure and prevent future stranded investments.
Recommendation: The Government should set out how it will learn lessons from the implementation of the Border Target Operating Model (BTOM), including the handling of costs for unused or under used border infrastructure. It should publish its position on compensation for …
Gov response: The government accepts this recommendation. We are already engaging with both port health authorities and port operators regarding impacts of SPS agreement implementation. Whilst we cannot provide a specific position on compensation at this point, …
No Published Response
#3 — Operation Kenova's implications for legacy inquiries and reconciliation warrant ongoing monitoring
Recommendation: The implications of Operation Kenova’s investigations, for future legacy inquiries, the policy of Neither Confirm Nor Deny and the Government’s approach to reconciliation, are of considerable continuing interest to us. Through ongoing and bespoke pieces of work, we plan to …
No Published Response
#23 — FCDO fails to centrally log lessons learned from major capital projects.
Recommendation: FCDO told us it had conducted lessons learned exercises for both the Washington and Ottawa projects and does so for all its major projects. However, FCDO does not currently record all its lessons in a single central log. FCDO told …
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
#5 — Restart centrally collecting and analysing lessons learned from all FCDO estate capital projects.
Recommendation: Some FCDO high-profile estate projects have run significantly over time and budget. FCDO carries out large scale estate capital projects to refurbish or replace its buildings, but some recent projects, such as in Washington D.C. and Ottawa, have run significantly …
Gov response: The government agrees with the Committee’s recommendation. applying lessons learned across its capital programme to strengthen organisational oversight, improve risk management, and ensure that investment decisions benefit from the work of previous projects. The FCDO …
Accepted
#12 — NS&I leadership slow to act on advice, offering limited lessons from Programme issues.
Recommendation: The external organisations that have reviewed the programme told the NAO that NS&I was sometimes or often slow to act, or did not act at all, on advice.29 We asked whether NS&I’s leadership had learned from the issues with the …
Gov response: The Treasury and NS&I acknowledge these concerns and are committed to addressing them through robust planning, risk management, and governance. NS&I is working to develop a comprehensive integrated plan that includes clear timelines, cost estimates, …
Response Pending
#10 — NS&I confident in delivery despite lack of plan, failing to justify programme approach.
Recommendation: Despite the lack of information on timetable and cost, NS&I claimed it was confident that it could find a way to deliver the Programme by 2028, by “deprioritising” some aspects of the Programme.22 When asked how it could be confident …
Gov response: The Treasury and NS&I acknowledge these concerns and are committed to addressing them through robust planning, risk management, and governance. NS&I is working to develop a comprehensive integrated plan that includes clear timelines, cost estimates, …
Response Pending
#2 — Seek positive attestation on NS&I implementing culture review recommendations and leadership learning lessons.
Recommendation: NS&I’s positive news culture has meant it has not learned lessons, which has affected its ability to deliver the programme. NS&I told us that that it promotes a “can do” attitude and culture; while this has benefits in encouraging commitment …
Gov response: The government agrees with the Committee’s recommendation. of business-wide cultural change activity to respond to the findings of the culture review and other sources of colleague / supplier / stakeholder feedback. An initial plan will …
Accepted
#9 —
Recommendation: The Cabinet Office recognises that other challenges government faces, such as the response to Covid-19, will also require cross-government working, working at pace, or working in new ways.18 The Cabinet Office feels that it has learnt a lot from EU …
Gov response: 2.3 The UK Transition PIC draws on recommendations from a comprehensive internal evaluation and summary report produced in January 2020 on the ‘Get Ready for Brexit’ (GRFB) campaign, and the NAO report. For example: ● …
Not Addressed
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Cabinet Office and HM Treasury (the Treasury) about the learning for government from preparations for EU Exit.1 The C&AG’s report drew together lessons …
Gov response: Based on a report by the National Audit Office, the Committee took evidence on 8 October from the Cabinet Office and HM Treasury (HMT). The Committee published its report on 2 December 2020. This is …
Not Addressed
#4 —
Recommendation: EU Exit preparations involved more than 22,000 civil servants at the peak and have cost at least £4.4 billion. But there has been no serious attempt to reflect and capture lessons for other challenges that government faces. Every government department …
Gov response: 2020. The department is revising the structures through which the contracts are managed to ensure that roles are more clearly defined and sufficiently resourced for all aspects of contract management to operate fully effectively. It …
Under Consideration
#3 —
Recommendation: As the then Minister of State, Lucy Frazer, acknowledged to us, one reason for the failure of the 2014–15 Transforming Rehabilitation reforms was inaccurate modelling of how much work, and therefore profit, would go to the private sector and third …
Gov response: Partly This recommendation has been partly agreed as the decision to discontinue to Probation Delivery Partner competitions was taken following a review process. We never enter into a procurement with the intention of cancelling it; …
Under Consideration
#2 —
Recommendation: This is the second major probation reform programme in the last five years. The unplanned-for effect of covid-19 has only added to the challenges the Probation Service faces. The lessons of the previous, failed reforms must be learned, and the …
Gov response: The government welcomes the Committee’s support for a unified probation service. In designing the new unified model, we have sought to learn lessons from Transforming Rehabilitation and have drawn on the insight from reports by …
Under Consideration
CQC Inspection Actions (2)
ICIBI Immigration Recommendations (7)
A further inspection of the EU Settlement Scheme July 2020 – March …
Recommendation 2 Making best use of management information (MI) and ‘lessons learned’ and ‘improvements made’ stories, expand and regularly update its messaging regarding the length of time an application will …
An inspection of visit visa operations December 2022 to January 2023
Cease the use of routing, decision-making and enrichment practices, including unassured information sources such as ‘Enrichment OneNotes’, that are not compliant with policy. Managers should provide decision makers with solutions …
An inspection of visit visa operations December 2022 to January 2023
Conduct a review to ensure that the CARS tool reflects the full range of known immigration risks to the UK and that a mechanism exists to incorporate new and emerging …
An inspection of visit visa operations December 2022 to January 2023
Review the ‘interim’ status of the Complexity Application Routing Solution (CARS) and declare the Home Office’s long-term intentions
An inspection of the Border Force intelligence functions at the Humber ports …
Continue to review the tools and technology used by intelligence officers and frontline staff to maximise the benefits of intelligence and targeting opportunities by:ensuring they enable staff to undertake their …
An inspection of the Border Force intelligence functions at the Humber ports …
Review the communications strategy for the MINERVA programme to ensure that the end state of MINERVA and how it will be delivered is clearly defined and communicated to staff.
An inspection of the Border Force intelligence functions at the Humber ports …
Review the tasking process at the Operational Intelligence Tasking and Co-ordination Group (Ops ITCG) to improve its effectiveness, including:provision of a clear escalation mechanism to the Intelligence Tasking and Co-ordinating …
NAO Audit Recommendations (393) — showing 50 strongest matches
Increasing the capacity of the prison estate to meet demand
MoJ should improve its case for bolstering the resilience of the estate by evaluating: lessons learned from delivering the prison expansion portfolio; and
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
The Cabinet Office should routinely gather and disseminate lessons learned from organisational changes across government. It should engage with all departments who have undergone MoG changes to obtain lessons learned and use this to review, update and publish its guidance …
Accepted
The government’s resources and waste reforms for England
Defra should carry out a lessons-learned exercise in advance of the formal evaluation of the reforms to determine practical steps that could be taken to help avoid the challenges it has faced recurring in its future resources and waste work. …
Accepted
Supporting investment into the UK
DIT should draw out lessons from the first two years of the OFI, to inform DIT?s transformation programme and its approach to managing investors. This should also help inform further development of the OFI.
Accepted
Supporting local economic growth
• capture and apply lessons learned at key points in the design and delivery of new local growth funds.
Accepted
The challenges in implementing digital change
c) disseminate and apply lessons learned from the successes and failures of the past and seek to understand why digital strategies have made poor progress.
Accepted
Crossrail – a progress update
The Department and TfL should examine the types of benefits realised by the Crossrail programme and Elizabeth line, and those benefits expected but not achieved, and take account of their learnings in the business cases and benefits strategies for other …
Accepted
Improving the performance of major equipment contracts
The Department is developing a programme of important reforms, some of which are at a relatively early stage. To support this agenda and to complement the recommendations in our recent report on the Department’s 2020–2030 Equipment Plan, we recommend that: …
Partially accepted
Carrier Strike – Preparing for deployment
e) conduct in-depth lessons-learned exercises on the Carrier Enabled Power Projection projects. The Department should ensure that it assesses the factors that lead projects to succeed or fail, including the root causes, and disseminate the lessons so that they are …
Accepted
Completing Crossrail
For the Department’s other current and future major programmes: d) We note that the Department has completed a lessons learned exercise and we would encourage it to also apply the lessons to other major projects including High Speed 2.
Accepted
NHSE's management of elective care transformation programmes
The national level oversight board should play an active role in ensuring that lessons are learned on and between the transformation programmes. Practical steps may include reviews, workshops or problem-solving sessions to allow everyone involved to share their perspectives and …
Accepted
Lessons learned: Governance and decision-making on mega-projects
For mega-projects, HM Treasury and NISTA should strengthen the project gateway and business case approval processes to ensure that government has assurance about the affordability, value for money and feasibility of the project before it is given final approval to …
Accepted
Lessons learned: Governance and decision-making on mega-projects
the roles and responsibilities of those who may not be directly involved in governance but are part of the broader government decision-making landscape, such as HM Treasury, cross-government or departmental programme boards, mission and leads, and NISTA, are clear and …
Accepted
Lessons learned: Governance and decision-making on mega-projects
Any alternative governance approach should also ensure that: ? roles and responsibilities are clear across those charged with governance and those involved with decision-making; this is particularly critical where decisions and accountabilities stretch across a system or set of organisations;
Accepted
Lessons learned: Governance and decision-making on mega-projects
HM Treasury and NISTA should consider using alternative governance approaches for the projects it determines are mega-projects to ensure those who have the authority to make decisions are accountable for the impact of those decisions on the project. This could …
Accepted
Government's general grant schemes
To achieve greater, proportionate monitoring and evaluation of grant schemes, the Grants Management Function should: (h) work with departments and the Evaluation Task Force to explore different approaches to identifying, sharing and using lessons learned, to inform and improve the …
Accepted
Progress on the Buckingham Palace Reservicing programme
Identify the lessons it has learnt and discuss these with the Infrastructure and Projects Authority (IPA) and HM Treasury to decide a set of lessons for major projects, particularly for heritage projects and those taking place in a live environment. …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
The Cabinet Office should ensure there is proper consideration of the costs and benefits of major MoG changes and provide longer-term support and guidance to departments facing significant organisational change. Once the decision has been taken to implement a MoG …
Partially accepted
Rail reform: the rail transformation programme
Over the next year, DfT should develop its understanding of how it can successfully deliver rail reform, including any potential pilots it could undertake, so that it is well placed to advise ministers early in the next Parliament. This work …
Accepted
Levelling up funding to local government
DLUHC should develop its plans to disseminate learning and insight from its evaluations in a timely way and engage with local authorities to maximise understanding of what works prior to waiting for final evaluation reports.
Accepted
Levelling up funding to local government
DLUHC should further use the learning from the process and impact evaluation to build an evidence base of what works to stimulate local economies.
Accepted
Levelling up funding to local government
Given the delays to projects across the Levelling Up Fund and Towns Fund, DLUHC should set out what further action it is going to take if projects cannot be completed within the existing funding deadlines. This could include resetting expectations …
Accepted
Resilience to flooding
h in the next 12 months, develop a plan of work to investigate the reasons for the increased inaccuracy and uncertainty in its business case forecasts and, based on the findings, put in place remedial actions
Accepted
Support for innovation to deliver net zero
DSIT, working with DESNZ, should by October 2023 identify the lessons learned from the development of the cross-government Net Zero Research and Innovation Framework. These lessons should be documented and actively considered in future to aid consistent and effective support …
Accepted
High Speed Two: Euston
DfT and HS2 Ltd should apply the lessons from Euston to the HS2 Manchester stations and other parts of Phase 2b of the HS2 programme. These should include: ? ensuring that a robust estimate is used to set the budget …
Accepted
High Speed Two: Euston
As part of planning an affordable and deliverable station, DfT and HS2 Ltd should learn lessons from how other projects have approached a reset, including those we set out in our report on resetting major programmes. This will include having …
Accepted
Investigation into the UNBOXED festival
identify lessons for the future about the importance of agreeing clear objectives and then setting performance targets early enough in any similar future programme?s lifecycle
Accepted
Investigation into the UNBOXED festival
identify lessons for the future from the experience of how projects have performed against their targets, including on cost and attendance, and the split between physical and digital/broadcast audiences;
Partially accepted
Government Shared Services
k) Departments working together as clusters should each complete a ?lessons identified? assessment to demonstrate how they have taken on board lessons from previous strategies and share these with the Cabinet Office.
Accepted
Supporting local economic growth
Given the challenges of carrying out high-quality evaluation, the Department should also: • carry out a prioritisation exercise to identify and fill the most important gaps in its evidence; and
Accepted
Supporting local economic growth
The Department should set out and publish its plans to formally evaluate the Levelling Up Fund and the UK Shared Prosperity Fund in line with the Magenta Book’s emphasis on the importance of planning an evaluation early. It should ensure …
Accepted
The decommissioning of the AGR nuclear power stations
The Department and HM Treasury should draw upon the lessons from the AGR arrangements when informing strategies for funding the decommissioning of new nuclear stations. This should include consideration of how the taxpayer’s position can be protected for the longer …
Accepted
BBC savings and reform
• undertake more consistent identification and dissemination of lessons arising from its delivery of savings measures;
Accepted
Progress with trade negotiations
DIT should ensure it learns lessons from the progress it has made on multiple negotiations so far. It should ensure that feedback, learning and sector knowledge from across departments and devolved administrations is recorded and shared, and used to inform …
Accepted
Improving Single Living Accommodation
The Department (and specifically, DIO) should work with the Commands to introduce, as soon as possible, a booking system that is easy to use and reduces costs. It must ensure lessons have been learned from its previous experiences and from …
Accepted
Progress report: Terminating the Magnox contract
d) ensure that its subsidiaries have the capacity to test, challenge and validate supplier information in a timely way, maintaining assurance as a primary activity in the management and oversight of the work at all times.
Accepted
Progress report: Terminating the Magnox contract
c) ensure that its subsidiaries have the capability to design and manage complex contracts; and
Accepted
Progress report: Terminating the Magnox contract
With input from the Government Commercial Function, the NDA should: b) explore with its subsidiaries what contractual levers can be included in future contracts to support the timely and effective management of underperformance;
Accepted
Progress report: Terminating the Magnox contract
With specific reference to the Magnox contract the NDA should: a) expedite its work to review the standard of quality assurance processes for asbestos and consider whether it should recoup fees from CFP.
Accepted
NHSE's management of elective care transformation programmes
Having brought oversight of the outpatients transformation into the wider elective recovery programme, NHSE should: ? make a full assessment of the lessons learned to date. NHSE should set out how these lessons will be incorporated in its plans for …
Accepted
Lessons learned: Governance and decision-making on mega-projects
HM Treasury and NISTA should develop how they categorise major projects according to their risk and strategic importance. In particular, they should define a category for ?mega-projects? that may require a different approach to governance and specify the criteria for …
Accepted
Dangerous cladding: the government’s remediation portfolio
MHCLG should share any relevant learning with the Public Sector Fraud Authority and the Cabinet Office Complex Grants Advice Panel. It should also report the results of such an exercise in its annual report and explain how it is using …
Accepted
Dangerous cladding: the government’s remediation portfolio
MHCLG should assess the feasibility of conducting a measurement exercise to estimate the extent of undetected fraud and error across its remediation portfolio. A measurement exercise would help it to understand the scale of the problem and whether further investigations …
Partially accepted
Progress on the Buckingham Palace Reservicing programme
The IPA and HM Treasury should share the lessons with government?s project delivery and project assurance and review communities. This could mean, for example, that the IPA adds the lessons to the government?s project delivery hub, includes examples on its …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should formally review what was de-prioritised from the Transformation Portfolio when creating the Integration Portfolio, to ensure that nothing has been missed, and build it into future activity. FCDO should: ? ensure that the lessons learned, and feedback from …
Accepted
Rail reform: the rail transformation programme
If DfT aims to deliver reform at speed in the future, it should fully assess the benefits of this approach and the risks to implementation and ensure there are contingencies in place. In making decisions about whether to proceed at …
Accepted
Investigation into the East West Rail project (Oxford – Cambridge)
To maintain an affordable programme of work, DfT and EWR Co should reflect on learning from other recent rail projects and assure themselves that they have adequate controls and governance in place to monitor and manage costs.
Accepted
The BBC’s implementation of Across the UK
e set out a revised communications and engagement strategy. Building on its learning from phase one, the BBC should set out plans for sustaining culture change from ATUK. As it moves into phases two and three, it needs to collect …
Accepted
The BBC’s implementation of Across the UK
c set out a benefits management strategy and plans for measuring changes in audience portrayal and economic growth without further delay. The plan should set out the baseline against which benefits will be measured, how benefits measured relate back to …
Accepted
The BBC’s implementation of Across the UK
Building on the work the BBC has underway as it moves into phase two of ATUK, it should: a review changes it has made to ATUK since March 2021, including the underlying data it is using to track these, to …
Accepted
IMB Annual Reports (15)
East Sutton Park (2021)
HMP East Sutton Park is an open prison for women, commended by the Board for being a safe and well-run establishment during a period affected by the Covid-19 pandemic. Key strengths include strong healthcare provision, effective resettlement preparation with good accommodation and employment outcomes, and valuable educational programmes. Challenges persist with ensuring prisoners are transferred with sufficient time to serve, effectively utilizing the IEP scheme for disruptive behaviour, and managing weekend medication administration.
PRISON
Key concerns
Channings Wood (2021)
HMP Channings Wood maintained a largely settled environment during a challenging year of Covid-19 restrictions, with notable reductions in self-harm, assaults, and substance misuse. The prison adapted its healthcare and education provisions effectively, earning commendations from Ofsted and HM Inspectorate of Probation for education and resettlement services respectively. However, significant concerns persist regarding staffing shortages impacting key worker schemes and offender management, the backlog in offending behaviour programmes, and ongoing issues with property transfers and resettlement accommodation.
PRISON
Key concerns
Ford (2021)
HMP Ford experienced a challenging year marked by Covid-19 restrictions, which the prison successfully managed, limiting outbreaks and reducing violence. Significant accommodation changes occurred with the condemnation of B wing and the introduction of new pods, which, despite initial issues, led to a reduced but more modern estate. The Board commended the prison's efforts in restoring and increasing external employment opportunities for prisoners post-restrictions, contributing positively to resettlement goals.
PRISON
Key concerns
Fosse Way (2024)
HMP Fosse Way opened in May 2023 as a category C prison and quickly reached its operational capacity of 1715 prisoners by February 2024. The IMB's first annual report highlights significant building design flaws, including inadequate facilities and security concerns, alongside staffing shortages and regime limitations. Despite successful integration of vulnerable prisoners, the rapid population increase led to a rise in self-harm and violent incidents, coupled with insufficient purposeful activity and education provision.
PRISON
Key concerns
Rochester (2025)
Rochester experienced an exceptionally challenging year marked by leadership instability and an HMIP Urgent Notification highlighting long-standing failures. While safety metrics showed improvement and staff interactions with prisoners were generally positive, the prison grappled with dilapidated infrastructure, persistent property issues, and staffing shortages impacting the regime. Major cohort changes were implemented too quickly, creating significant logistical demands.
PRISON
Key concerns
Hatfield (2022)
HMP/YOI Hatfield, a Category D resettlement prison, was found to be a safe environment with no recorded self-harm, staff assaults, or prisoner assaults during the reporting year. The prison demonstrated excellence in work and education provision, achieving high employment rates on release, and healthcare was well-managed. However, significant concerns persist regarding the poor and unhygienic condition of ablution facilities across both sites and the lack of funding for their essential refurbishment.
PRISON
Key concerns
Feltham (2022)
HMP/YOI Feltham reported a population of 348 young people and young adults at the end of the reporting year. While physical health and general well-being are met, the prison struggles with serious long-term mental health issues. Safety remains a significant concern, with a notable increase in violence and use of force incidents post-Covid, alongside challenges related to staffing, disrepair of the estate, and the regime's adaptation to larger groups. The IMB identified several key concerns, including inadequate time out of cell, insufficient support for looked after children, and issues with prison fabric and gang culture.
PRISON
Key concerns
Ford (2022)
HMP Ford is largely deemed a safe environment with fair and humane treatment, effective healthcare, and strong resettlement efforts. However, significant concerns remain regarding unsuitable prisoner arrivals, chronic understaffing in Probation, and a deteriorating prison estate, including outdated accommodation and delays in new builds. The Board also highlights issues with procurement, the lack of consistency in property rules nationally, and challenges in catering and post-release accommodation.
PRISON
Key concerns
Highpoint (2022)
HMP Highpoint, a Category C training and resettlement prison with an operational capacity of 1,270, experienced a decrease in self-harm but a 28% increase in violent incidents during the reporting year. Persistent concerns include significant maintenance backlogs by GFSL, ongoing issues with lost prisoner property, and restricted library access. Despite these challenges, healthcare provision maintained a 'green' rating, and the key worker scheme continued its development.
PRISON
Key concerns
Holme House (2022)
HMP Holme House demonstrated significant improvements in 2022, effectively recovering from Covid-19 disruptions and enhancing safety, healthcare, and resettlement services. While the prison maintained a safe and humane environment, key challenges included slow estate maintenance, deterioration in food quality, and the disproportionate impact of a growing young adult population on violence and self-harm. The IMB also highlighted issues with contractual transparency and the provision of adequate programs for vulnerable prisoners, making several recommendations to address these concerns.
PRISON
Key concerns
Featherstone (2022)
HMP Featherstone experienced a challenging year, marked by significant staffing issues that disrupted the regime and various services, including healthcare and purposeful activity. The prison's aging infrastructure is a major concern, along with the inadequate management of mentally ill prisoners in segregation. While violence reduced and overall safety improved, issues with staff culture, property management, and inconsistent use of body-worn cameras persist.
PRISON
Key concerns
Channings Wood (2024)
HMP Channings Wood has navigated a challenging year following the closure of HMP Dartmoor, resulting in significant population changes and regime disruptions. While staff resilience and a downward trend in self-harm and assaults are positive, the prison faces persistent issues with property loss, inadequate infrastructure maintenance, and delays in access to purposeful activity. Concerns also remain regarding the care of an expanding ageing population and the plight of IPP prisoners.
PRISON
Key concerns
Ford (2024)
HMP Ford, a Category D open prison, generally provides a safe and humane environment, with commendable improvements in induction processes, security measures, and a strong focus on rehabilitation through education and employment. However, the Board remains concerned about the failing building infrastructure, including critical boiler issues, inadequate phone provision, and persistent delays from probation services impacting prisoner progression and resettlement. The ongoing delay in the prison expansion project and budget cuts to vocational training are also significant concerns.
PRISON
Key concerns
Downview (2025)
HMP/YOI Downview, a women's closed prison and YOI, reported an average population of 319 against an operational capacity of 356. Key concerns include significant delays in mental health transfers for acutely unwell prisoners, persistently low rates of Release on Temporary Licence, and extremely high levels of property loss during inter-prison transfers. While staffing levels were generally healthy, the Board noted inconsistencies in staff effectiveness and operational oversight, alongside ongoing impacts of population pressure on safety and regime delivery.
PRISON
Key concerns
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
IMB Recommendations (32)
Cookham Wood (2024)
The Board recommends that there should be close scrutiny of the decisions taken in this restructure and re-roling of a YOI to determine lessons learned and how those lessons are being disseminated.
Other
Thorn Cross (2025)
A new building was almost complete when it had to be demolished because there were so many faults with it. What lessons have been learnt to prevent this happening again? (7.3.4)
HMPPS
Hewell Grange (2020)
The closure process adopted at Hewell Grange should be utilised as a case study for senior management development.
HMPPS
Lowdham Grange (2024)
Have lessons been learned from the transfer of prison management from one private provider to another at HMP Lowdham Grange, and is action being taken to avoid the significant negative impact on prisoners and staff occurring at any future transfer between private prison operators?
Ministry of Justice
Fosse Way (2024)
The Board is seriously concerned about prison build shortcomings, which have been identified in the report. What will the Minister do to avoid the same errors being repeated in future builds (one of which we believe is due to open near York in the coming year)?
HMPPS
Fosse Way (2024)
The Board is seriously concerned about prison build shortcomings, which have been identified in the report. What will the Minister do to avoid the same errors being repeated in future builds (one of which we believe is due to open near York in the coming year)?
Ministry of Justice
Eastwood Park (2020)
In her reply to our previous annual report, the minister stated that the new offender management unit (activities centre) building remained a priority project, and that (subject to caveats) work on it was likely to start by the first quarter of 2021. Is this still the expectation?
Ministry of Justice
Dartmoor (2020)
How will the Prison Service ensure that prisoners are not disadvantaged by the lack of investment in Dartmoor in the lead-up to the proposed closure in 2023?
HMPPS
Dartmoor (2020)
The planned closure of HMP Dartmoor in 2023 is having a significant impact on prisoners’ experience and staff morale. When will the minister provide clarity on the closure plans for the prison, so that detailed plans can be made for the future of all stakeholders?
Ministry of Justice
Belmarsh (2020)
Will the minister direct HMPPS to allocate funding for this works programme and to ensure that it takes place in 2020/21 (see section 5.1)?
Ministry of Justice
The Mount (2021)
The MoJ’s statisticians should take this as an opportunity to assess the effectiveness of these programmes in stopping re-offending.
Ministry of Justice
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that the Home Office identify the learning that arises from both of these projects and builds that learning into future design, commissioning and oversight procedures and practices.
Home Office
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that the Home Office and Contractor undertake a review of learning from the floor works project. The review should incorporate the many concerns identified in this report, including a breach of STHF rules, The content and results of that review should be shared with the Board.
Other
Bedford (2024)
The long delay and design issues associated with the relocation of the CSU suggest some basic flaws in understanding how prisons work and a lack of consultation with local managers. When will the Prison Service address this issue?
HMPPS
Werrington (2025)
How are interventions programmes evaluated and what evidence is there of their success?
HMPPS
Warren Hill (2025)
Further follow-up work is developed so that the effectiveness of the Warren Hill regime can be assessed against the recall rates.
Governor / Director
Hewell (2025)
What measures will the Prison Service take to ensure that funded pilot schemes, such as the HMP Hewell Here-to-Help peer mentorship programme, include metrics and criteria for success, as well as a contingency plan for scaling up if successful?
HMPPS
Featherstone (2020)
Despite expenditure on a refurbishment programme, much of the residential accommodation, such as windows, heating and showers, is below the standard expected in the 21st century. While there has been some improvement in the operation of the maintenance contract, prison managers are often frustrated by the lack of progress, which is outside of their remit. How will the minister support …
Ministry of Justice
Erlestoke (2020)
GFSL continues to disappoint (see paragraphs 7.2 to 7.6). Will the Minister consider ways in which radical changes can be made to ensure a responsive and well-managed system for repairs and improvement?
Ministry of Justice
Aylesbury (2020)
Share a clear set of nationally agreed priority improvements in young prisoner employment and vocational training, to ensure a much improved use of resources over a two- to five-year period. Back this effort with collection and analysis of appropriate data.
Ministry of Justice
Thorn Cross (2021)
The number of places in the open estate nationally has fallen, which means there are a number of prisoners who are unable to benefit from the rehabilitative culture they offer and so aid a reduction in reoffending.
Ministry of Justice
Swinfen Hall (2021)
Will the Minister assure the Board that there will be an improvement in contract monitoring and adequate supervision of works carried out in the prison estate?
Ministry of Justice
Dartmoor (2021)
Continue to track the recommendations from last year’s IMB annual report, which have been in abeyance because of the Covid-19 regime.
Governor / Director
Bristol (2021)
It would also be useful to share details of how various initiatives are aligned to key areas for improvement, so we can better monitor and report on developments.
Governor / Director
Thorn Cross (2022)
To learn from the experiences of the recent introduction of extra accommodation, resulting in better planning and implementation of any future new accommodation (5.1.1).
Governor / Director
Portland (2022)
Will the minister address the serious shortcomings in the management processes within HMPPS particularly with reference to poorly planned reforms introduced to the service?
Ministry of Justice
Oakwood (2022)
The Board is concerned that after three years this framework has not yet been published (see section 5.8).
Ministry of Justice
Feltham (2020)
What do you and your team consider to be the principal lessons learned over the lockdown period? How will the prison use these lessons to improve the lived experience for all young people and young adults held in custody at Feltham?
Governor / Director
Deerbolt (2020)
The Minister should agree that lessons can be learned from the COVID-19 lockdown, particularly regarding the reduction in violence and loss of rehabilitative interventions. Planning should be undertaken to devise regimes and activities that capture the benefits of lockdown while restoring targeted activities aimed at reducing reoffending.
Ministry of Justice
Warren Hill (2021)
The Board is pleased that the long-awaited upgrade in telephone and information technology data lines have been undertaken and that plans are well advanced for the installation of in-cell telephony at Warren Hill. However, the Board notes with regret that the opportunity was not being taken to install in-cell laptops at the same time (see section 7.4.3).
HMPPS
Bristol (2022)
The Board wishes to receive more regular updates on performance indicators and progress reports on various initiatives. Can this be provided more often?
Governor / Director
Dartmoor (2022)
With the appointment of the new head of business assurance, will the Governor continue to track and report on the implementation of the recommendations from the IMB, HMIP and other report recommendations?
Governor / Director
Detention Investigations (2)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 18
IND pulls together the lessons on design from the Yarl’s Wood experience (size, long corridors, siting of the control room, construction materials etc) and ensures that they underpin the production of any future footprints or alternative designs submitted by contractors.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 12
• Contractors be required to draw up and implement action plans following any serious incident. The plans should incorporate all lessons learned and, where those lessons are generic, should be applied across all the contractor’s centres; • IND monitors implementation within agreed timescales; • IND ensures that contractors prepare contingency …
Immigration Detention