No open learning culture
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
882 items
16 sources
19 inquiries
Source spread
Where this theme appears
No open learning culture has been flagged across 16 independent accountability sources:
55 inquiry recs
267 PFD reports
358 committee recs
19 CQC actions
4 HMICFRS recs
3 ICIBI recs
29 PPO recs
5 IOPC recs
30 NAO recs
4 PHSO recs
11 IMB reports
77 IMB recs
12 Article 2 learning points
1 detention investigation rec
5 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (55) — showing 50 strongest matches
RHI-36 — Learning from Failures
Recommendation: The Northern Ireland Civil Service should develop a better process to learn from past failures, one that goes beyond the traditional method of revising and circulating internal guidance. Leaders within the Senior Civil Service must be more systematic, persistent and …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
26 — Ensure Home Office staff presence and visibility in IRCs
Recommendation: The Home Office must ensure that its staff are regularly present and visible within each immigration removal centre.
Gov response: Detention Engagement Team expansion is underway, with further recruitment to increase Home Office staff presence in IRCs.
Accepted in Part
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-94 — Review firearms officer Post Incident Procedures delays
Recommendation: The College of Policing should assess whether delays in the provision of written accounts by some firearms officers involved in the response to the Attack were due to Post Incident Procedures. If so, those procedures should be reviewed.
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-51 — Address Showsec failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made by Showsec to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
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-50 — Address Arena failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made at the Arena to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
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
LADB-17 — Develop a blame-free culture for safety information communication in industry
Recommendation: The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Unknown
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
P2-34 — London Fire Brigade to establish lessons learned process
Recommendation: That the London Fire Brigade establish effective standing arrangements for collecting, considering and effectively implementing lessons learned from previous incidents, inquests and investigations. Those arrangements should be as simple as possible, flexible and of a kind that will ensure that …
Gov response: London Fire Brigade accepts all the recommendations relevant to them, including this one aimed directly at them. London Fire Brigade is committed to ensuring lessons from incidents are learned from and good practice is shared …
Accepted
In progress
FENN-54 — Produce prompt reports and analysis of fire and smoke incidents
Recommendation: Reports of fires and smoke shall be produced promptly and an analysis made available for management and Board meetings, the Railway Inspectorate, the London Fire Brigade, and the London Regional Passengers' Committee.
Unknown
BRIS-112 — Conduct structured analysis of sentinel events considering organisational factors
Recommendation: All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of individuals, but also the wider contributing factors within the organisation which may have …
Unknown
HIDD-92 — Promptly update Rule Book and Books of Instruction incorporating report observations
Recommendation: The Rule Book and Books of Instruction of a similar status shall be promptly updated and observations made in this Report taken into account.
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Unknown
HIDD-9 — Introduce national testing instruction with workforce explanation, monitoring, and auditing
Recommendation: BR shall introduce a national testing instruction with all speed. Such introduction shall be accompanied by a full explanation to the workforce, including workshops or seminars as necessary. Implementation must be monitored and audited.
Unknown
F119 — Learning and information from complaints
Recommendation: Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.
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
F118 — Learning and information from complaints
Recommendation: Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F57 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
LAMI-30 — Directors must ensure senior managers regularly inspect children's social services case files
Recommendation: Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes.
Unknown
FENN-56 — Chief Safety Inspector to review, identify hazards, recommend policies, and audit safety
Recommendation: The Chief Safety Inspector shall review existing safety arrangements, identify hazards, recommend policies, objectives and systems to meet those hazards, and thereafter audit the effectiveness of the system. He should have direct access to the Chief Executive of London Underground …
Unknown
FENN-44 — Encourage trade union participation in all internal inquiries
Recommendation: Trade union participation in internal inquiries shall be encouraged.
Unknown
LADB-39 — Establish system for signaller briefing and information sharing after SPAD incidents
Recommendation: Railtrack should institute a system whereby all signallers in the signal box (or centre) are briefed by their line manager following a SPAD in their area, and there is appropriate dissemination of information which may be of assistance to signallers …
Unknown
LADB-35 — Train SPAD investigators in human factors and root cause analysis
Recommendation: Persons who investigate, and make recommendations as a consequence of, SPADs should be trained in the identification of human factors and in root cause analysis. Their competence in these areas should be formally recorded, and renewed by refresher courses. The …
Unknown
LADB-33 — Review SPAD Group Standard to avoid presuming driver error as sole cause
Recommendation: The Group Standard on SPADs and its associated documentation should be reviewed to ensure that there is no presumption that driver error is the sole or principal cause, or that any part played by the infrastructure is only a contributory …
Unknown
HIDD-47 — Report 6-monthly to Railway Inspectorate on Automatic Train Protection implementation progress
Recommendation: BR shall report at 6 monthly intervals to the Railway Inspectorate on its progress in implementing ATP.
Unknown
HIDD-42 — Report 6-monthly to Railway Inspectorate on accident follow-up and recommendations
Recommendation: BR shall report at 6 monthly intervals to the Railway Inspectorate on its follow-up to the Clapham Junction accident and implementation of its own and this Report's recommendations.
Unknown
HIDD-38 — Urgently use outside consultants to review safety management and communication issues
Recommendation: The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.
Unknown
HIDD-8 — Require BR to provide and monitor full documentation for proper testing
Recommendation: BR shall ensure that full documentation is provided and later monitored in order that proper testing is carried out.
Unknown
R75 — Health Board review of IPC reports
Recommendation: Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place.
Gov response: Section 2.1 highlights the report's recommendation for NHS boards to review existing inquiry reports from the UK and other jurisdictions to learn lessons and implement necessary measures (recommendation 75). While the response details how NHS …
Accepted
R74 — Review of UK IPC reports
Recommendation: Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the UK and in other relevant jurisdictions on infection prevention and control and patient safety are …
Gov response: Section 2.1 notes the report's call for the Scottish Government to ensure timely review and implementation of relevant measures from existing inquiry reports, including those from other jurisdictions, as a matter of standard practice (recommendation …
Accepted
R72 — Internal investigation independence
Recommendation: Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
Gov response: Section 3.2 notes that the report addresses issues in NHS boards relating to internal investigations (recommendation 72). While the "Our current position" section discusses feedback, complaints, and the introduction of a statutory duty of candour …
Accepted
F101 — National Patient Safety Agency functions
Recommendation: While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer review inspections or the inclusion in Patient Environment Action Team …
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
F1 — Implementing the recommendations
Recommendation: It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work; Each such organisation should announce at the …
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
AR-2 — Protocol for Post-Incident Debriefing
Recommendation: At an early date there should be liaison between the IPCC, the MPS and ACPO (and, more significantly, lawyers acting for each) with a view to establishing a protocol for the future conduct in the event of a shooting by …
Gov response: No formal government response published. MPS provided updates on 12 August 2014 confirming work on post-incident debriefing protocols.
Accepted
RHI-34 — Rapid Response Capacity
Recommendation: The Northern Ireland Civil Service should have regard to best practice elsewhere about how to respond effectively when serious problems emerge, such as those that did so with the non-domestic NI RHI in the summer of 2015, by, for example, …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
FENN-72 — Institute and maintain cleaning and maintenance standards for London Underground
Recommendation: London Underground must institute and maintain a set of standards for cleaning and maintenance.
Unknown
FENN-71 — Implement job specifications and inspection for all maintenance and cleaning activities
Recommendation: Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.
Unknown
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
FENN-50 — Maintain formal health and safety monitoring system at all management levels
Recommendation: London Underground shall maintain a formal system for health and safety monitoring at all levels of management.
Unknown
FENN-43 — Ensure director-level consideration of internal accident inquiry recommendations
Recommendation: The recommendations of internal inquiries into accidents must be considered at director level.
Unknown
SHI-4 — Standard form for derogations from guidance
Recommendation: The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
CR4 — Training on normalcy bias
Recommendation: HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in particular, assumptions about exaggeration in calls from small boats.
Response Pending
IHRD-83 — SAI Deaths in Annual Reports
Recommendation: Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
Gov response: SAI-related death reporting incorporated into Trust annual reports.
Accepted
No update 2+ yrs
IHRD-82 — Policy on Learning from SAI Deaths
Recommendation: Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
Gov response: Trusts have published policies on responding to and learning from SAI-related deaths.
Accepted
IHRD-81 — Board Awareness of SAI Reports
Recommendation: Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
Gov response: Procedures established for ensuring Board members receive all SAI-related reports.
Accepted
12 — Review incident investigation structures
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
PFD Reports (267) — showing 50 strongest matches
Muniza Mehrban
Concerns: This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention measures at the location.
Overdue
Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet
Concerns: Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units to minimise this risk.
Overdue
Carol Ann Gibson
Concerns: A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
Overdue
Stephanie Daniels
Concerns: Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
Response (Manchester Mental Health NHS): Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning …
Response (Manchester Clinical Commissioning Groups): The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has …
Response (Department of Health): The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the …
Responded
Martin McGlasson
Concerns: Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.
Response (DWF): Lightwater Quarries Ltd has implemented a newly adopted Risk Assessment & Method Statement as the basis for training, Turning Circle awareness and management, changes in lifting from the crane, safety …
Responded
Daniel Williams
Concerns: Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Response: The Trust has implemented a patient record development programme which provides alerts to staff, states a patient centred approach, and has rolled out training for staff and improved patient handovers. …
Responded
John Davies
Concerns: GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal or self-harming behaviours.
Overdue
Agostino Costa
Concerns: Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
Overdue
Jackson Chadd
Concerns: Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Response (Frimley Park Hospital): The Hospital updated sepsis guidelines to include tachycardia, changed practices to fast track children with PEWS scores of less than 4 to the Paediatric Assessment Unit, and now requires blood …
Response (Royal College of Paediatrics Child Health): The RCPCH refers to existing guidance, standards and reports regarding supervision and training and notes their current review of standards to encourage higher levels of consultant supervision.
Overdue
Eric Matthews
Concerns: There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
Response (University Hospital London NHS Trust): The Trust investigated a survey of 'cot deaths' in unusual scenarios but it did not prove feasible due to data protection and consent issues. They suggest coroners liaise with clinicians …
Responded
Dana Baker
Concerns: Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Response (Safeguarding Children Board): The WSCB acknowledges the concerns but states that national practice is followed and questions if the report should have been directed to the Department for Education. The guidance in place …
Responded
Lloyd Butler
Concerns: A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Response (West Midlands Police): West Midlands Police instigated misconduct procedures against officers and staff involved, resulting in disciplinary sanctions. They have provided clear guidance on dealing with individuals arrested for being drunk and incapable, …
Responded
Monique Whitbread
Concerns: A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.
Overdue
Thomas Taylor
Concerns: The ward lacked clear leadership and support, there was no protocol for lost notes and drug charts, and there seemed to be no well-understood protocol when the patient refused a blood sugar check.
Overdue
Anne Sandever
Concerns: A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, with no adequate hospital investigation following.
Response: The Trust conducted an investigation and implemented a Trust-wide action plan, including spot checks on wards, a specific training program for recognizing deteriorating patients, and ensuring effective communication. They have …
Responded
Janet Goodacre
Concerns: The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.
Response (University Hospitals of Leicester NHS Trust): University Hospitals of Leicester NHS Trust has established a process where each RCA investigation has a named 'Chair', introduced RCA Oversight training for RCA Chairs, and established a new 'Adverse …
Responded
Phyllis Kerry
Concerns: There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.
Response (Nottingham University Hospitals NHS Trust): A new guideline has been prepared to improve the management of anticoagulation in patients with intracerebral hemorrhage, clarifying specialty responsibilities. The specialties involved are currently consulting with colleagues to finalize …
Response (Nottingham University Hospitals NHS Trust2f): A new guideline for treating warfarin patients with intracranial hemorrhage has been agreed and will be communicated to medical staff and included in specialty inductions. The guideline group will also …
Responded
Agnes Hannan
Concerns: Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.
Response (Tameside Hospital NHS Trust): The hospital replaced its computer system for medical records, is purchasing a scanner for the A&E department to improve record accessibility, and has reviewed and updated its DNACPR policy, emphasizing …
Responded
Sandra Higham
Concerns: A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.
Response (BHRS): BHRS will include an article on avoidance and recognition of atrio-oespohageal fistula in its winter newsletter and remind members to ensure this complication is recorded in the national cardiac rhythm …
Response (UK Health Security Agency): Public Health England states that the case is not something they can directly assist with, but understand that the Department of Health will contact appropriate bodies.
Response (Department of Health): The Department of Health contacted the BCS who are considering circulating a letter to relevant surgeons. A copy of the coroner's letter and the response from the Department of Health …
Responded
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
Simon Alliston
Concerns: A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was needed. No serious incident investigation followed his death.
Response (SEPT): The trust has made changes to its Serious Incident reporting process, ensuring clinical information is made available, decisions are taken by Executive Directors, and the process no longer requires confirmation …
Responded
Tanya Page
Concerns: Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Overdue
Jane Robinson
Concerns: Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.
Response (University Hospitals of Leicester NHS Trust): The Trust is implementing a competency assessment for HCAs by the end of October 2015 and moving towards electronic recording of observations with automatic EWS calculation and alerts. Clinical handover …
Responded
Thor Dalhaug
Concerns: Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust has implemented changes to staff induction, supervision, and investigation procedures following the death. A fresh SUI report was undertaken and process changes were underway to …
Responded
Tamara Holboll
Concerns: The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.
Response (Camden and Islington NHS Trust): Camden and Islington NHS Trust has amended the action plan template and revised guidance for writing recommendations, adding an action row to prompt authors to write an action for each …
Responded
Doreen Wood
Concerns: Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.
Overdue
Sheila Johnson
Concerns: The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Response (Department of Health): The Department of Health states that officials have made enquiries with the Trust and have been assured that it will respond appropriately. The CQC will follow up any actions identified …
Response (Tameside Hospital NHS Trust): Tameside Hospital has made considerable changes to improve internal investigations and patient discharge processes, including a review of senior nursing and medical staffing and revised procedures for incident investigations. A …
Responded
Wanda Stachurska
Concerns: Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Response (Surrey and Borders Partnership NHS Trust): The Trust has worked with East Surrey Hospital to ensure a shortcut to SASH policies is loaded onto Psychiatric Liaison staff computers, and has mandated that two staff members undertake …
Responded
Arthur Fry
Concerns: A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Response (University Hospitals North Midalnds NHS Trust): University Hospitals of North Midlands NHS Trust is incorporating a phrase into the MRI safety questionnaire about MRI compatibility. The Department of Imaging has applied for transformation funding for Imaging …
Responded
Isabella Drew
Concerns: Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding advice and support for pregnant women about whooping cough vaccination. They note that NHS England is responding on behalf of the …
Response (NHS England): NHS England will consider the coroner's concerns about integrating pertussis and immunisation services into routine maternity care as part of an independent review of maternity services in England. Public Health …
Responded
Simon Reynolds
Concerns: Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.
Overdue
Dean Joseph
Concerns: Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Response: The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers …
Responded
William Tolen
Concerns: Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.
Response (William Tolen): Staff have received further supervision and training in relation to documentation, and instructions have been added to staff diaries. Staff have been requested that requests are stated clearly and that …
Responded
Vasilis Ktorakis
Concerns: The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, an error of judgement in allowing passive descent, and a systemic issue in learning from incidents.
Response: The response details multiple actions already completed including educational supervision for the registrar involved, sharing learning points via newsletters and meetings, and implementing a meeting at the start of every …
Responded
Carl Foot
Concerns: Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.
Overdue
Angela Brealey
Concerns: The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Response (South Staffordshire and Shropshire Healthcare NHS Trust): The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, …
Overdue
Ronald Bentley
Concerns: A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.
Response (BCIS): The British Cardiovascular Intervention Society (BCIS) circulated the report to its members via its official newsletter and passed on details to the British Heart Rhythm Society (BHRS).
Overdue
Rubana Pathan
Concerns: Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, potentially delaying diagnosis and treatment for patients with breast implants.
Response (Homerton University Hospital NHS Trust): The hospital disseminated information about Staphylococcal Toxic Shock Syndrome to clinicians, including an evidence and literature search. The case will be discussed at a Hospital Grand Round, and the Trust …
Overdue
Jonathan Lander
Concerns: A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.
Response (J Lander): The Trust has implemented a Substance Misuse Information Sharing Protocol with Swanswell Worcestershire Recovery Partnership. Action Plans from Root Cause Analyses are now uploaded to an Embedded Lessons Database, monitored …
Responded
Kathryn Bull
Concerns: Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with symptoms that are not well known.
Overdue
Patricia Steer
Concerns: Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there was a lack of accessible guidance on this critical safety point.
Response (NHS England): NHS England clarifies that responsibility for the National Patient Safety Alerting System has transferred to NHS Improvement. It then refers to previous safety alerts and guidance related to central line …
Responded
Leilani Chute
Concerns: Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified by the Trust's internal investigation.
Response (Western Sussex Hospital NHS Trust): Western Sussex Hospitals NHS Trust has audited the practice of manually pushing back the cervix, provided feedback to staff involved, and is offering additional training on cardiotocograph (CTG) interpretation and …
Responded
Stephen Bird
Concerns: Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
Response (South Buckinghamshire Hospitals): South Buckinghamshire Hospitals has taken several actions including re-auditing patient records, implementing mandatory training on documentation, and introducing a monthly audit of discharge documentation; a RCA report was also completed.
Responded
Dominic Travis
Concerns: The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by a lack of independence and transparency due to being conducted by directly involved staff.
Overdue
Andrew Machin
Concerns: Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his death.
Overdue
Shelia Stokes
Concerns: Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by an incomplete internal investigation.
Response (Sherwood Forest Hospitals NHS Trust): Sherwood Forest Hospitals NHS Trust has determined that following referral of Mrs. S to the vascular team, a letter was sent to Mrs. Stokes on 15 July 2015. Following this …
Response (Radiology Department): The Radiology Department will review and modify its XXXX policy to take account of electronic reporting and a referrer acknowledgement system.
Responded
Amanda Coulthard
Concerns: Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
Response: The Department of Health acknowledges concerns about nasogastric tube misplacement and refers to ongoing work, including an NIHR-funded project at the University of Hull to develop a location-indicating NGT.
Response (North Cumbria University Hospitals Trust): The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 …
Responded
Michael Parke
Concerns: Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
Response: The Department of Health acknowledges the need for consistent implementation of patient safety requirements for nasogastric tubes. They are considering the evidence and economic implications of routine pH testing and …
Response (North Cumbria University Hospitals Trust): The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 …
Responded
Michelle Lawrence
Concerns: Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
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
Committee Recommendations (358) — showing 50 strongest matches
#9 —
Recommendation: It is clear that further work needs to be done on the way in which the prison service more generally responds to recommendations. It is important for all organisations that they are able to learn from external sources of assurance. …
No Published Response
#18 — Committee welcomes DIO offer to share key lessons on safety inspections.
Recommendation: We welcome the offer from DIO to share its key lessons learned on gas and electrical safety inspections. (Recommendation, Paragraph 82)
Gov response: The MOD accept the recommendations regarding the management of Landlord Gas Safety Inspection (LGSI) certificates and Electrical Installation Condition Report (EICR) certificates and the need for improved access protocols. We acknowledge there are situations where …
Accepted
#5 — MOD's performance recovery claims demand demonstrable improvement in customer experience and trust.
Recommendation: The MOD’s claims of a recovery in performance need to be borne out in a demonstrable improvement in the customer experience and markedly increased customer satisfaction. Service families’ trust has been affected and the DIO and service providers need to …
Gov response: The MOD accepts the recommendation and agrees with the conclusion set out in 4 and 5. The DIO is working closely with its IPs, Families Federations and Service Personnel and their families to identify performance …
Accepted
#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
#21 — Cultural change represents the hardest aspect of DWP's service transformation programmes.
Recommendation: DWP acknowledged that cultural change can be the hardest part of any transformation programme. It told us that this requires leadership to help people understand the change that is coming, why the change is a good 35 Qq 19-20 36 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The department recognises that successful service modernisation requires long-term, genuine systemic and organisational culture change. It is fostering a cultural shift by enhancing behaviours, …
Accepted
#4 — Set out monitoring and mitigation strategies for cultural change risks in service modernisation.
Recommendation: Realising the benefits of service modernisation will require strong leadership to embed cultural change within DWP and its outsourced providers. DWP’s Service Modernisation Programme is an 11–year organisation-wide programme estimated to cost £312.1 million, running from 2022–23 to 2032–33, which …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The department recognises that successful service modernisation requires long-term, genuine systemic and organisational culture change. It is fostering a cultural shift by enhancing behaviours, skills, and …
Accepted
#25 — Home Office refuses to publish extensive lessons learned review from large site acquisitions.
Recommendation: When we questioned the Home Office about repeated mistakes in its acquisitions of large sites, it explained that it was learning from multiple projects at the same time. The Home Office informed us that its lessons learned review identified over …
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
#4 — Address cultural issues allowing Home Office controls and processes to be overridden too easily.
Recommendation: We are concerned that the Home Office’s culture allowed it to override too easily the controls and processes in place to protect taxpayers’ money. The Home Office appears to have been operating in crisis mode for several years and now …
Under Consideration
#9 — Companies House and HMRC lack understanding of company register fraud's link to tax losses.
Recommendation: Companies House said that, prior to the introduction of the Economic Crime and Corporate Transparency Act (ECCTA), it estimated that 5% of UK registered companies were fraudulent. It explained that external commentators had estimated the figure could be as high …
Gov response: 1b. PAC recommendation: HMRC should ensure it works with Companies House and the Insolvency Service to understand how the amount of corporate fraud affects the tax gap. It should lay out how it plans to …
Accepted
#24 — UK's extensive nutrition and food security research resources remain underutilised.
Recommendation: The UK has a tremendous array of research institutes and a strong history of contributing to the fields of nutrition and food security. There is more the Government could be doing to make use of these resources and to integrate …
Gov response: Partially Agree. The decision on what the UK will spend its future ODA budget on is being worked through following the decision to reduce UK ODA from 0.5% of GNI currently to 0.3% in 2027. …
Not Addressed
#25 — Residents still lack sufficient information and transparency regarding their building's remediation progress
Recommendation: In 2020 the previous Committee noted that many residents were not being kept informed about the process of remediation and requested that MHCLG set out how it would improve transparency.42 We therefore asked whether government was now doing enough to …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2025 3.2 The government will write to the Committee annually from Summer 2025, until Summer 2029 when, in alignment with the RAP, all …
Accepted
#20 — Government still faces challenges in robustly evaluating and sharing AI pilot learning.
Recommendation: We questioned DSIT on how it is evaluating and sharing learning from AI pilot activity across government to avoid reinventing the wheel and to support AI adoption at scale. It told us that it was taking a range of approaches …
Gov response: 4. PAC conclusion: DSIT has no systematic mechanism for bringing together learning from pilots and there are few examples of successful at–scale adoption across government. 4a. PAC recommendation: To learn from AI pilots and support …
Accepted
#19 — Systematic knowledge sharing on government AI adoption remains absent.
Recommendation: The NAO report set out the importance of knowledge sharing to learn from pilot activity, encourage innovation, promote consistent standards, and avoiding duplication of effort in AI adoption across government. However, it also reported that there was no systematic dissemination …
Gov response: 4. PAC conclusion: DSIT has no systematic mechanism for bringing together learning from pilots and there are few examples of successful at–scale adoption across government. 4a. PAC recommendation: To learn from AI pilots and support …
Accepted
#4 — Establish mechanism for AI pilot learning and scale successful products across government.
Recommendation: DSIT has no systematic mechanism for bringing together learning from pilots and there are few examples of successful at–scale adoption across government. At the time of the NAO report (March 2024), levels of AI use in government were low, but …
Gov response: The government agrees with the Committee’s recommendation. enable more successful scaling within departments and across organisational boundaries, ultimately realising better outcomes for government and for citizens from these technology investments. A proposal is currently being …
Accepted
#15 — Declining trust in HMRC attributes to substandard services and broader global governmental trends.
Recommendation: We asked about taxpayers’ declining trust in HMRC. HMRC said there had been a decline in trust globally with governments and with public bodies, and it was also subject to that decline. It told us that it had not been …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 HMRC recognises five drivers of customer trust, being perceptions of fairness, competence, transparency, reciprocity and prevalent social norms. 2.3 HMRC uses its annual customer …
Not Addressed
#14 — Taxpayer trust in HMRC has declined for most groups since the 2020 strategy launch.
Recommendation: In July 2020 HMRC and HM Treasury published the Tax Administration Strategy (the Strategy) which set out how they would build a modern, trusted tax administration system by 2030.23 As part of the Strategy they wanted to gradually increase the …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 HMRC recognises five drivers of customer trust, being perceptions of fairness, competence, transparency, reciprocity and prevalent social norms. 2.3 HMRC uses its annual customer …
Accepted
#2 — Require HMRC to understand and address declining taxpayer trust, publishing concerns and actions.
Recommendation: Taxpayers’ trust in HMRC is falling. Trust in a tax authority is vital for the authority to effectively discharge its role as it affects the willingness of taxpayers to engage and pay the correct amount of tax on time. HMRC …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented HMRC publishes the results of its annual surveys as well as a range of other customer feedback (for example, via exercises like public consultation). The Exchequer …
Accepted
#18 — Departments remain reluctant to share cyber incident information, hindering collective learning.
Recommendation: We asked the Cabinet Office what the impact was when departments did not share information about their cyber incidents. The Cabinet Office agreed that sharing data is essential to learn lessons, understand vulnerabilities, share best practice and work out what …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2026 3.2 The government recognises the importance of embedding security expertise at the heart of departmental decision making. 3.3 There is a clear …
Accepted
#17 — Establish protocols for Defra's professional information sharing and investigate policy leaks.
Recommendation: Defra should ensure that operational and policy decisions are clearly communicated to its arm’s-length bodies and the farming advice service in advance of them being made public. It should investigate the causes of the leaks of its proposed changes to …
Gov response: Government officials mark communications handling documents with sensitive information OFFICIAL SENSITIVE and only share on a need-to-know basis for colleagues delivering the work. On the day prior to an announcement, we circulate the lines to …
Not Addressed
#16 — Review and evaluate Government communication with farming sector, providing analysis and solutions.
Recommendation: The Government should review how it communicates with the farming sector and properly evaluate the impact recent communications have had on trust in the Department. It should provide its analysis and proposed solutions in its response to this report. (Recommendation, …
Gov response: Our commitment to farming and food security is steadfast. As a result of the Government’s determination to get more farmers to participate, there are now 50,000 farm businesses and half of all farmed land now …
Accepted
#15 — Improve Defra's proactive and transparent communication with Parliament and arm's-length bodies.
Recommendation: We are thankful to the Secretary of State, Ministers and Officials for engaging with our Committee, but we urge Defra to improve its communication with Parliament and be proactive and transparent in its communications. Similarly, communications between Defra and its …
Gov response: The Government agrees that Parliamentary scrutiny is vital to effective policy development and good Government. The Government always strives to keep Parliament updated, and Ministers act in accordance with the Ministerial Code, as circumstances permit. …
Not Addressed
#14 — Defra's poor communication and last-minute decisions erode trust in farming sector
Recommendation: The experience of the Sustainable Farming Incentive 2024 (SFI24) closure follows a pattern within Defra of poor communication and last-minute decision-making following rumours and Departmental leaks. As with the sudden closure of the Capital Grants scheme in November 2024, the …
Gov response: Our commitment to farming and food security is steadfast. As a result of the Government’s determination to get more farmers to participate, there are now 50,000 farm businesses and half of all farmed land now …
Not Addressed
#6 — Require Government to consult stakeholders and clearly communicate ELMS future direction
Recommendation: A transparent policy on the direction of the Environmental Land Management Schemes (ELMS) and other subsidy arrangements is crucial. If the Government is serious about improving ELMS outcomes it must consult with stakeholders and communicate its plan clearly. Confidence in …
Gov response: Our commitment to farming and food security is steadfast. As a result of the Government’s determination to get more farmers to participate, there are now 50,000 farm businesses and half of all farmed land now …
Not Addressed
#17 — Government lacks comprehensive understanding of effective VAWG interventions and mechanisms to share good practice.
Recommendation: Government departments have a limited understanding of what works to tackle violence against women and girls (VAWG). Since 2021–22, the Home Office has spent at least £4.2 million on new research into what works, but the projects funded are not …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The recommendation is being implemented through work undertaken to support the VAWG Strategy and any ongoing analytical work on tackling VAWG. 4.3 The Home …
Accepted
#9 — Home Office failed to sufficiently embed specialist VAWG sector expertise in strategy development.
Recommendation: Throughout its 2021 VAWG Strategy, the Home Office did not make the most of the available expertise and knowledge, for example by engaging with the voluntary sector to understand the demands being faced on the frontline.17 Evidence submitted by End …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 Through ministerially chaired VAWG thematic roundtables with sector experts, delivery partners, academics, policing, local practitioners and government departments, and regular stakeholder meetings held by …
Accepted
#4 — Require Home Office to capture and share evidence of successful local VAWG initiatives.
Recommendation: The Home Office has a limited awareness of initiatives proving effective so cannot use this information to improve its understanding of what works to prevent and reduce violence against women and girls. The Home Office acknowledges that departments do not …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The recommendation is being implemented through work undertaken to support the VAWG Strategy and any ongoing analytical work on tackling VAWG. The Home Office regularly reviews …
Accepted
#2 — Improve government departments' understanding of domestic abuse survivors' experiences and local service demands.
Recommendation: Government departments do not have a realistic understanding of the experiences of survivors seeking support, nor the demands faced by local services on the ground. Government departments appear to have a starkly different understanding of the support provided to survivors …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented Through ministerially chaired VAWG thematic roundtables with sector experts, delivery partners, academics, policing, local practitioners and government departments, and regular stakeholder meetings held by the Interpersonal …
Accepted
#6 — Prohibit non-disclosure and confidentiality agreements in cases of sexual misconduct, harassment, and discrimination.
Recommendation: The Government should urgently bring forward legislative proposals to prohibit the use of non-disclosure and other forms of confidentiality agreements in cases involving (a) sexual abuse, sexual harassment or sexual misconduct; (b) bullying or harassment not falling within (a), and …
Gov response: The Government acknowledges that non-disclosure agreements (“NDAs”) have their legitimate purposes, for example to protect intellectual property or financial information. However, they should never be used to take unfair advantage of workers, who may be …
Accepted
#12 — Efficient waste retrieval demands constant iteration, strong performance culture, and sophisticated, transparent target setting.
Recommendation: We explored with the witnesses what Sellafield Ltd needs to do to reach the point where retrieving waste becomes an efficient, routine activity. As well as installing the right equipment, they emphasised the importance of “constant iteration” – addressing problems …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: March 2027 2.2 Currently there are mission-length plans spanning 100+ years for each Operating Company (OpCo) within the NDA group. These reflect the best …
Accepted
#13 — Adopt a 'leading from behind' approach to share MOD expertise with other departments.
Recommendation: The Ministry of Defence should proactively adopt a greater ‘leading from behind’ approach to sharing its leadership, organisational and wider expertise with other departments to bolster their intrinsic long-term resilience planning and preparedness. This should reduce their demands on the …
Gov response: The MOD’s purpose is to protect the nation, leading on defence and the use of the Armed Forces. It is working closely with other Government departments, including playing a leading role in the development of …
Accepted
#3 — Care-experienced young people's voices vital and require broader inclusion across government levels.
Recommendation: We were privileged to hear powerful and insightful evidence from care-experienced young people in this inquiry, and their voices have informed many of the conclusions and recommendations in this report. We are pleased that the Department is regularly hearing from …
Gov response: The Department draws on the lived experience and knowledge of its care experienced staff through the Children and Young People Board run by the National Children’s Bureau on behalf of the department. The board has …
Accepted
#2 — Assess and report on improving accountability for family justice system by December 2025.
Recommendation: The family justice system is complex, but excessive fragmentation hinders transparency, leading to poor accountability for service improvement and overall performance. The family justice system involves many organisations across government and the independent judiciary. There is no single body accountable …
Gov response: The government agrees with the Committee’s recommendation. weaknesses of current governance arrangements with a view to improving accountability and transparency, along with better supporting the National and Local Family Justice Boards. Departments will write to …
Accepted
#24 — Engage stakeholders early to protect UK standards and unlock market access opportunities.
Recommendation: We recognise that the GT-EPD lays important foundations for reducing non- tariff barriers. The Committee urges Government to engage stakeholders early to ensure that future commitments protect UK standards while unlocking market access opportunities. (Recommendation, Paragraph 135)
Gov response: The PM, Business Secretary and other Ministers across Government have been engaging widely with business organisations and companies from across the economy, including discussions on non-tariff barriers. This is in addition to the close and …
Accepted
#22 — Work with industry to prevent UK-US economic alignment creating unintended trade obstacles.
Recommendation: The Government should work closely with industry to ensure that closer UK– US alignment on economic security measures, such as investment screening and export controls, does not create unintended obstacles for legitimate trade and collaboration. It should provide clear guidance …
Gov response: Economic security cooperation on areas outlined in the EPD, including investment screening and export controls, will ensure that the UK and US focus on outcomes reflecting our shared national security interests. We will continue to …
Accepted
#10 — Work with industry to monitor, allocate, and expand the 100,000-vehicle automotive quota.
Recommendation: The Government must work with industry to closely monitor use of the 100,000-vehicle automotive quota under the GT-EPD, agree a clear, fair mechanism for its allocation and management, and, given the complementary nature of the US and UK automotive industries, …
Gov response: The EPD General Terms secured an annual tariff rate quota for imports to the US of UK-produced passenger vehicles, at a tariff rate of 10%. From 1 January 2026, the annual quota of 100,000 vehicles …
Accepted
#7 — Set out a clear timetable for parliamentary scrutiny and stakeholder engagement of implementing measures.
Recommendation: We further recommend that the Government set out, in advance of ratification, a clear timetable for parliamentary scrutiny and stakeholder engagement and of any implementing measures, so that Members and affected sectors can assess the implications of the deal before …
Gov response: The previous Secretary of State for Business and Trade delivered statements to the House regarding UK-US trade on 2 April, 12 May and 18 June, and the previous Minister for Trade delivered a statement on …
Accepted
#23 — Commit to clear timelines, a delivery plan, and prompt communication during BTOM transition.
Recommendation: During the transition away from the BTOM, the Department should commit to clear timelines for decision-making, a delivery plan, and communicate changes promptly to allow businesses to plan with confidence. (Recommendation, Paragraph 40)
Gov response: The Government accepts this recommendation. We agree with the committee that it is vital to ensure timelines for decision making and delivery are communicated throughout the transition from the BTOM to the UK-EU SPS Agreement …
Accepted
#22 — Future border policy development requires structured, transparent stakeholder consultation from the outset.
Recommendation: Future border policy development must include structured, transparent, and iterative consultation with stakeholders from the outset to ensure policies are workable and informed by the sector. (Conclusion, Paragraph 40)
Gov response: The Government accepts this recommendation. We agree with the committee that it is vital to ensure timelines for decision making and delivery are communicated throughout the transition from the BTOM to the UK-EU SPS Agreement …
Not Addressed
#19 — Co-design BCP cost recovery mechanisms with industry and publish Sevington Inland BCP operational costs.
Recommendation: If the Government continues to operate a BCP within the common SPS area, any cost recovery mechanism must be co-designed with industry and should not disproportionately affect small and medium-sized enterprises. In the interest of transparency, the Government should publish …
Gov response: The Common User Charge (CUC) is utilised only at Sevington, as the only Government operated BCP currently in Great Britain. The CUC operates on a cost recovery model to fund the operational costs of the …
Partially Accepted
#18 — Develop future border cost recovery mechanisms collaboratively with industry to rebuild trust.
Recommendation: Border control posts recover costs whilst operating as the least-cost, high-efficiency solution for border checks. Industry trust in the Common User Charge has been undermined by a perceived lack of transparency in cost recovery processes and concerns over the widespread …
Gov response: The Common User Charge (CUC) is utilised only at Sevington, as the only Government operated BCP currently in Great Britain. The CUC operates on a cost recovery model to fund the operational costs of the …
Not Addressed
#8 — Require Defra to provide Sevington BCP lorry data, validate re-exported goods, and assess commercial sealing.
Recommendation: In an annex included in the response to this Report, Defra should provide us with the August and November 2024 figures relating to the number of lorries that were directed to Sevington Inland BCP for border checks and the number …
Gov response: Defra regularly reviews the data picture for Sevington BCP, including analysis of non-attendance and understands the importance of this for understanding compliance levels. The analysis of our data shows declining rates of non-attendance over time. …
Partially Accepted
#6 — Require Defra to provide risk assessment models and underlying data for SPS inspection rates.
Recommendation: Defra should, in response to this Report, provide us with the risk-based assessment models and underlying data used to determine SPS inspection rates. Publicly available models will enhance transparency, allow for independent scrutiny, and help rebuild stakeholder confidence in the …
Gov response: The Government agrees that providing transparency to the risk-based assessment models is of benefit and have outlined the regime below. For SPS controls, our approach under the BTOM is a risk-based regime covering live animals, …
Not Addressed
#5 — Transparency and accuracy lacking in SPS control models undermine trust and scrutiny.
Recommendation: There is a critical need for greater transparency and accuracy in the modelling and implementation of SPS controls. A failure to publish risk assessments and data informing inspection rates, limits scrutiny and undermines trust in the system. Addressing these issues …
Gov response: The Government agrees that providing transparency to the risk-based assessment models is of benefit and have outlined the regime below. For SPS controls, our approach under the BTOM is a risk-based regime covering live animals, …
Not Addressed
#2 — Require Defra to publish a thorough review of BTOM implementation and quarterly port inspection rates by January 2026.
Recommendation: It is essential that Defra thoroughly reviews the implementation of the BTOM. Defra should commit to this review in its response to our Report, and the review must be published no later than January 2026. It should set out why …
Gov response: The Government acknowledges the Committee’s comments and agrees that understanding inspection rate performance across Border Control Posts (BCPs) is an important part of effective border oversight. We intend to do further work to improve our …
Partially Accepted
#19 — Implement SEND reforms gradually through phased pilots with full parental engagement and communication
Recommendation: To avoid causing undue alarm and to help rebuild confidence and trust in the system, parents and carers must be fully engaged and any reforms must be implemented gradually and in a carefully phased manner. New approaches should first be …
Gov response: Shared. Education, health and care services should work in partnership with one another, local government, families, teachers, experts and representative bodies to deliver better experiences and outcomes for all our children. The Ministerial team and …
Not Addressed
#18 — Families of children with SEND lack trust in the system due to poor communication
Recommendation: Children and young people with SEND, and their families, have little trust and confidence in the SEND system, often shaped by adverse experiences. Inadequate communication and engagement from the Department with parents and carers and their organisations about future reforms, …
Gov response: Shared. Education, health and care services should work in partnership with one another, local government, families, teachers, experts and representative bodies to deliver better experiences and outcomes for all our children. The Ministerial team and …
Accepted
#31 — FCDO acknowledges data limitations in operating contexts and provides flexibility for partners.
Recommendation: It is also positive that the FCDO recognises that the lack of data in many of the contexts it operates in means that some quantitative metrics are not possible or of good quality, and offers flexibility around this for operating …
Gov response: Partially agree. The FCDO is committed to ensuring that MEL requirements do not create barriers for smaller organisations. Teams are expected to apply MEL proportionately and in accordance with PrOF Rules, which allow for adjustments …
Accepted
#30 — FCDO demonstrates a strong monitoring, evaluation, and learning culture and processes.
Recommendation: We have been glad to hear that there is a stronger evaluation culture in the FCDO than can be seen in many other Government departments, and that the FCDO’s monitoring, evaluation and learning (MEL) processes are strong in comparison to …
Gov response: As the IDC recognises, the FCDO is a world leader in its approach to VfM and has built upon the strong legacy from the former DFID.
Not Addressed
#24 — Convene regular strategic dialogues with philanthropists and development foundations for aligned work.
Recommendation: We recommend that the FCDO convenes regular strategic dialogues with philanthropists and development foundations to ensure that work can be aligned and complementary, and to encourage knowledge sharing. (Recommendation, Paragraph 75)
Gov response: Partially agree. Partnerships with philanthropic organisations are important. The FCDO is committed to deepening these to drive the government’s new approach to international development. The FCDO’s existing engagement through formal frameworks and informal collaboration covers …
Partially Accepted
CQC Inspection Actions (19)
Agnes House 81
Quality monitoring systems were not robust. There was a lack of evidence that the provider was continually evaluating the service and making the required improvements.
Must Do
Laurel Lodge Care Home
The provider must ensure that effective governance systems are established and operated to monitor the quality of the service, identify risks to the health and safety of people, and drive continuous improvement.
Must Do
Highfield House Residential Home
The provider must ensure good governance.
Must Do
Charlton House Medical Centre
Insufficient action had been taken since our comprehensive inspection in June 2021, such that there were no peer reviews of work undertaken by GPs, GP locums, nurses and healthcare assistants which continued to place patients at risk of harm.
Must Do
Tralee Rest Home
Further time and development was required to ensure the measures in place were wholly effective in sustaining progress and driving forward the continuous improvement of the service.
Should Do
Orton Manor Nursing Home
Ensure good practices implemented since the last inspection become embedded into the culture of the home, under the new managers and with the new staff team, to ensure they are sustained, particularly when new people start to move to the …
Should Do
Knightwell House
We recommend the provider reviews best practice guidance and puts measures in place to assess and monitor the risks associated with a closed culture within the service.
Should Do
St Clare's Hospice
The provider should review the culture within the hospice and identify positive processes to improve current concerns. Specifically in relation to bullying.
Should Do
Southwinds
The provider must take the required actions when things go wrong within the service.
Must Do
Park Grange Care Home
We concluded, due to the lack of oversight regarding the reviewing and investigating of safeguarding concerns, the lack of analysis of accidents and incidents and the registered manager not having an understanding of lessons learnt.
Must Do
Benthorn Lodge
The provider must ensure that the manager is a visible presence at the service and contactable by staff, and that effective quality assurance systems are in place to obtain feedback, monitor performance, and manage risks on a regular basis.
Must Do
Nicholas House
The culture of the service did not promote high-quality care and support. Quality assurance systems were not robust enough to demonstrate the service was effectively managed.
Must Do
Bousfield Surgery
Take steps to formally record the challenges faced by the practice and how they are to be overcome as part of the strategy for promoting the vision and values of the practice.
Should Do
Baby Bump Limited
The manager should consider sharing the vision for the service with the staff.
Should Do
Winterton House
There must be displayed at each premises from which the service provider provides a regulated activities at least one sign showing the most recent rating by the Commission that relates to the service providers performance at those premises
Must Do
St Clare's Hospice
The provider should develop workable plans to turn their vision and strategy into action.
Should Do
The Warren Residential Lodge
people who lived at the home and their relatives did not always have a clear understanding of who the manager for the service was.
Should Do
The Gateway
The registered provider failed to act in an open and transparent manner around the proposed changes to the operational structure of the home.
Must Do
Parkside Residential Home
The rating from our previous inspection in March 2015 were not being displayed.
Must Do
HMICFRS Recommendations (4)
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures …
Recommendation
FRS 2021-22 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The service has shown a clear intent from the executive board to improve the culture of the service. However, more needs to be done throughout the organisation. We have found evidence of poor behaviours that are not …
Recommendation
An inspection of the effectiveness of the police and law enforcement bodies' …
With immediate effect, take effective steps to eradicate victim-blaming language in their forces
Recommendation
ICIBI Immigration Recommendations (3)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 9 Review the assurance regime at Stansted and relaunch it so that it is no longer regarded as a “tick-box exercise” with little value, ensuring that those responsible for …
An inspection of Border Force operations at Stansted Airport
Recommendation 9 Review the assurance regime at Stansted and relaunch it so that it is no longer regarded as a “tick-box exercise” with little value, ensuring that those responsible for …
An inspection of contingency asylum accommodation November 2023 – June 2024
Strengthen organisational learning in relation to asylum accommodation by producing a framework, with associated processes and guidelines, for capturing, evaluating and sharing learning (‘best practice’ and pitfalls) from ‘business as …
PPO Death in Custody Recommendations (29)
The Prison Group Director for East Midlands
The Prison Group Director for East Midlands should share the Ombudsman’s report with the regional safety lead.
The Governor of HMP Woodhill
The Governor of Woodhill should share this report with the Deputy Governor and CM A and discuss the Ombudsman’s findings with them.
The Governor
The Governor should ensure that all evidence about a death in custody, including electronic evidence, is retained and promptly made available to the Prisons and Probation Ombudsman, in line with PSI 58/2010.
The Governor at HMP Peterborough
The Governor at HMP Peterborough should ensure that a manager holds a hot debrief promptly after a death in custody and that all those involved in the incident, including healthcare staff, are invited to attend, in line with PSI 64/2011.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that evidence is made available to the PPO, in line with PSI 58/2010.
The Head of Healthcare
ensure that a copy of this report is shared with Dr A, and that his employing agency discusses the Ombudsman’s findings with him.
The Department of Home Affairs
The Department of Home Affairs should consider immediately commissioning an independent investigation in the event of any future non-natural deaths at Isle of Man Prison.
The Governor and Head of Healthcare (HMP Bristol)
The Governor and Head of Healthcare will want to consider this finding and conduct their own investigations to establish what happened and whether there is any learning.
The Governor
The Governor should ensure that this report is shared with Officer A and that a senior manager discusses the Ombudsman’s findings with him.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Director
The Director should share this report with PCO A and PCO B and ensure that a senior manager discusses the Ombudsman’s findings with them.
The Governor
The Governor should ensure that the Prisons and Probation Ombudsman is promptly provided with all requested documents following a death in custody, in line with PSI 58/2010.
The Governor
The Governor should investigate the staff culture on B Wing, including considering the number and nature of complaints submitted, and provide an update to the Ombudsman.
The Governor
The Governor should share a copy of this report with CM A and arrange for a senior manager to discuss the Ombudsman’s findings with him.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor of HMP Liverpool
The Governor should ensure that a copy of this report is shared with all staff named in this report so that they are aware of the Ombudsman’s findings.
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that a copy of this report is shared with the staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor
The Governor should share a copy of this report with Officer A and ensure that a senior manager discusses the Ombudsman’s findings with him.
The Head of Healthcare
The Head of Healthcare should share a copy of this report with Senior Nurse A and Nurse B and discuss the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should share this report with Nurse A and discuss the Ombudsman’s findings with her.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that this report is shared with all staff named in it and that they are given the opportunity to reflect on the learning involved.
The Governor and Head of Healthcare of HMP Liverpool
Healthcare staff were not invited to the debrief after Mr Fielding died. Those we interviewed said they had not felt adequately supported. We bring this to the attention of the Governor and Head of Healthcare.
The Director General of HMPPS
The Director General of HMPPS should communicate to Governors and Directors his expectation that in all but the most exceptional of circumstances, when there is evidence of making deliberate false entries, a formal investigation is instigated and, in appropriate circumstances …
The Head of Healthcare, alongside doctors involved in Mr Honnor’s …
The Head of Healthcare, alongside doctors involved in Mr Honnor’s care, should undertake a formal significant event analysis to identify weaknesses in the care provided and learning from these, and share these with all clinicians working in the prison.
The Governor
The Governor should ensure that, in accordance with PSI 64/2011, a manager holds a hot debrief promptly after a death in custody and that all staff involved in the incident, including healthcare staff, are invited to attend.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that this report is shared with all staff named in it and that they are given the opportunity to reflect on the learning involved.
The Governor of HMP Lewes
The Governor will wish to assure himself that the processes in place are adequate to ensure prisoners are offered appropriate support following a death in custody, in particular in the case of close friends of the deceased prisoner.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are offered appropriate support following a death in custody.
The Governor
The Governor should conduct a local investigation into the events of 27 June 2024, identify and share any learning with staff and the Ombudsman, and ensure that night patrol officers understand the equipment they are required to carry, when and …
IOPC Learning Recommendations (5)
Recommendations - Metropolitan Police Service, August 2021
The IOPC recommends the MPS ensures that changes implemented to develop a culture of openness, transparency, improve cross-team working and collaboration between teams are embedded and a clear plan is in place to support continuous improvement in this area. An …
Inappropriate photographs taken at crime scene – Metropolitan Police Service, June 2020
The IOPC recommends the Metropolitan Police Service reviews whether supervisors and senior management at Forest Gate Police Station are taking personal responsibility to identify and eliminate patterns of inappropriate behaviour, whilst simultaneously promoting a safe and open culture which makes …
Inappropriate photographs taken at crime scene – Metropolitan Police Service, June 2020
The IOPC recommends the Metropolitan Police Service take steps to ensure all officers within Forest Gate Police Station conform to the expectations of their behaviour under the Code of Ethics, whilst on and off duty, and are aware that failure …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police adopts the principles set out in the force FLO policy as best practice for all officers/staff when dealing with bereaved families. There should be clear agreement in advance about what information can be …
National recommendations - College of Policing, July 2024
The IOPC recommends the College of Policing and the National Police Chiefs’ Council (NPCC) work together to produce clear guidance on preservation of life at the scene of a hanging where death has not been confirmed. This should include guidance …
NAO Audit Recommendations (30)
Investigation into student finance for study at franchised higher education providers
establish a common anti-fraud and corruption culture and risk tolerance by, for example, encouraging the reporting of fraud and corruption and embedding discussions in risk management forums
Accepted
Investigation into whistleblowing in the civil service
d Cabinet Office should build on its efforts to help departments learn from different approaches to whistleblowing, focusing on areas such as supporting effective assurance by senior leaders and Audit and Risk Assurance Committees, understanding whistleblowers? experience and supporting the …
Accepted
Investigation into whistleblowing in the civil service
b Cabinet Office should work with departments to encourage them to use every concern raised as an opportunity to learn from whistleblowers, including those concerns where no wrongdoing is found;
Accepted
Managing conflicts of interest
Cabinet Office encourages each public body to commission their internal auditors to review their implementation of the standard, including whether mitigations have been properly implemented. To help with this, it should invite the Government Internal Audit Agency (GIAA) to participate …
Partially accepted
Managing conflicts of interest
Cabinet Office facilitates the creation of a temporary good practice forum which would allow public bodies to build networks and learn from each other as they implement the minimum standard;
Accepted
Investigation into whistleblowing in the civil service
c When data is available Cabinet Office should use it to establish the extent of whistleblower complaints of intimidation or victimisation, build an understanding of the number of and patterns in complaints, and consider any need to coordinate departmental action
Accepted
Investigation into whistleblowing in the civil service
a In order to build a fuller understanding of whistleblowing outcomes and what happens to whistleblowers, Cabinet Office should work with departments to improve the completeness of data, broaden the categories of data it collects and deepen the analysis it …
Accepted
Managing NHS backlogs and waiting times in England
c) Before April 2023, NHSE should set up independent evaluations of its major elective recovery programmes so that it is actively developing the evidence base for these initiatives.
Accepted
Regulating the financial sustainability of higher education providers in England
The OfS should: d) communicate more effectively with the sector to build trust in its approach as a regulator; improve providers’ understanding of its attitude to risk and how it defines risk-based, proportionate, regulation; and be more ready to share …
Accepted
Decommissioning Sellafield: managing risks from the nuclear legacy
Sellafield should: carry out an assessment of the culture across the site and develop suitable metrics to assess and monitor whether all areas of the site and its leadership are positively contributing to creating a high performing public sector organisation.
Accepted
Investigation into student finance for study at franchised higher education providers
increase activity to raise awareness among lead providers of the risks and benefits associated with using franchised providers. This could include sharing good practice and setting out the consequences (including student loan funding being recovered or commercial damage) should concerns …
Accepted
Investigation into student finance for study at franchised higher education providers
as a matter of urgency OfS and DfE should jointly reiterate to the higher education sector its role in preventing fraud and abuse, and particularly to lead providers that they bear direct responsibility for the governance and management practices of …
Accepted
Progress in improving mental health services in England
a) DHSC and NHSE should publish a detailed statement of what achieving full 'parity of esteem' between mental and physical health services encompasses, in terms of access and service standards, staffing model and funding allocations, and the road map for …
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
The production and distribution of cash
The Mint and the Bank should maximise opportunities to learn from each other’s experiences of cash production and work with the wider distribution system, for example working closely with industry, and making best use of available production capacity.
Accepted
Financial sustainability of colleges in England
e) Learn lessons from the first two college insolvency cases. This work should include evaluating the cost, timeliness and impact of the education administration process and identifying improvements for future cases.
Accepted
Financial sustainability of colleges in England
b) Assess systematically how far colleges are responding to financial pressures by narrowing their provision and reducing student support services. This work should include identifying colleges that have made efficiency savings without curtailing provision, and sharing this good practice across …
Accepted
Tackling the tax gap
c) while recognising that it is appropriate for HMRC to primarily organise its approach to compliance by risk and customer group, consider extending, where relevant to other tax gap behaviours, good practice shown in its tax avoidance strategy and approach. …
Accepted
BBC Studios
The BBC should: a) develop a clear plan for closing the cultural gap between the production and distribution arms of BBC Studios, including milestones and indicators for measuring its progress in achieving this.
Accepted
Government's general grant schemes
To improve grant practitioners' capability, the Grants Management Function should (f) explore further opportunities to share good practice, resources and experiences among grant practitioners within central and local government, such as holding in-person network meetings outside of London, and making …
Accepted
The effectiveness of government in tackling homelessness
We recommend that DLUHC should establish a way for local authorities to more easily understand innovative practice and potential solutions in homelessness services from other authorities.
Accepted
Investigation into student finance for study at franchised higher education providers
more systematically share data and testing results, such as from statistical testing to identify anomalies or targeted sampling of provider data audits, to better understand risks and focus investigative work
Accepted
Investigation into student finance for study at franchised higher education providers
develop further guidance for providers explaining what constitutes meaningful student course engagement and how it expects providers to self-assure data. As part of this, DfE should consider what SLC and OfS need to better assess the quality of provider data, …
Accepted
Progress in improving mental health services in England
e) As mental health services will need to remain the focus of sustained improvement and in the light of national and local reorganisation of health bodies, DHSC and NHSE should set out the future approach to leading, monitoring and assuring …
Accepted
Progress in improving mental health services in England
c) NHSE, working with local ICBs and providers, should improve its data and analysis to better understand the relative cost and cost-effectiveness of different services, and provide a more robust basis to decide future priorities.
Accepted
Central oversight of arm’s-length bodies
The Cabinet Office, departments and ALBs should work together to develop and share performance information between ALBs, to help identify opportunities for improvement.
Accepted
Protecting consumers from unsafe products
e) Examine how best to influence businesses and consumers to prevent problems from occurring. This could include business segmentation analysis to ensure regulators can influence harder-to-reach businesses and assessing what impact the OPSS could have by more directly trying to …
Accepted
Public Service Pensions
d) consider government’s overall approach to ensuring that employees understand their pensions, particularly for the three million scheme members affected by the McCloud judgment who will need reliable and timely information, including from scheme administrators, to make decisions about their …
Accepted
Public Service Pensions
b) resolve its concerns about the cost control mechanism and be open and transparent about the impact of any changes it makes for employers and scheme members;
Accepted
Achieving government’s long-term environmental goals
• defines the values and behaviours that will support delivery of its environmental goals, reviews how closely these align with its current working culture and sets out plans for improving and monitoring progress.
Accepted
PHSO Ombudsman Recommendations (4)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Ignoring the alarms: How NHS eating disorder services are failing patients
NICE should consider including coordination as an element of their new Quality Standard for Eating Disorders.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
IMB Annual Reports (11)
Moorland (2023)
HMP/YOI Moorland is a Category C public sector resettlement prison for adults and young offenders, also serving as a foreign national hub, with an operational capacity of 1,058. The report highlights generally good accommodation and staff-prisoner relationships, with improvements in healthcare waiting times and education access. However, key concerns persist regarding staffing levels impacting regime and key work, ongoing issues with illicit substances, and significant delays in mental health transfers to specialist units, alongside a lack of prisoner confidence in the complaints system.
PRISON
Key concerns
Low Newton (2023)
HMP/YOI Low Newton is a well-managed women's prison that successfully adapted its regime post-Covid. While praised for its safe environment, estate improvements, and dedicated staff, it is significantly hampered by staff shortages, impacting regime delivery and key worker scheme consistency. The Board highlights concerns regarding funding for essential facilities, the management of complex prisoners, and the need for improved transport arrangements and oversight of disciplinary processes.
PRISON
Key concerns
Standford Hill (2023)
HMP/YOI Standford Hill is recognized as a well-run Category D prison, excelling in resettlement and providing substantial opportunities for prisoners to gain skills and employment, contributing to low re-offending rates. The prison maintains a safe environment with zero reported self-harm, assaults, or deaths in custody during the reporting period, and healthcare provision has significantly improved. Key concerns include the persistent poor performance of GFSL, the potential negative impact of the TPRS on resettlement, and the need for scanning equipment and modern monitoring technology.
PRISON
Key concerns
Thameside (2023)
HMP Thameside, a local Category B/C prison, maintained a safe environment despite a high remand population and gang-related challenges, though prisoner-on-prisoner assaults increased. The transition to a new healthcare provider was problematic, negatively affecting prisoner access to care, and issues with property management and resettlement support persist. The Board also noted ongoing concerns regarding the effectiveness of the key worker scheme, in-cell computer systems, and delays in mental health transfers.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
This report highlights significant shortcomings in the Short-term Holding Facilities (STHFs) in Scotland and Northern Ireland. Key issues include a failure to separate men and women at Larne House, inadequate accommodation, and inconsistent healthcare provision often leading to the removal of essential medication. Detainees frequently face unnecessarily long stays due to systemic inefficiencies, coupled with a lack of transparency and accessibility challenges across the estate.
PRISON
Key concerns
Yarl’s Wood IRC (2024)
Yarl's Wood IRC experienced a 40% increase in detainee throughput in 2024, operating close to its 444-person capacity. While staff are commended for humane treatment and effective incident management, concerns persist regarding high levels of violence, inappropriate detention of vulnerable individuals, and poor information sharing. The Board highlights issues with prolonged detention, slow casework progression, and the inappropriate use of the CSU for mental health cases, noting that staff recruitment and retention remain challenging.
IRC
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
Hewell Grange (2020)
This report covers the final six months of HMP Hewell Grange as it underwent a planned closure, ceasing to hold prisoners by 31 March 2020. The Board found the prison generally safe and praised staff for their humane management of the closure, despite unacceptable living conditions. Healthcare provision was inconsistent, and purposeful activity was curtailed due to the closure, though efforts were made to minimise negative impacts on resettlement.
PRISON
Key concerns
Hewell (2020)
The COVID-19 pandemic significantly impacted HMP Hewell, leading to a full lockdown, 23.5-hour cell confinement, and cessation of most activities. While staff are commended for averting a direct catastrophic impact from the virus and improving cleanliness, concerns remain regarding prisoner welfare, mental health, and rehabilitation. The prison saw leadership changes and continued a journey of improvement after years of poor performance, with some areas showing progress despite ongoing challenges in safety, healthcare provision, and regime delivery.
PRISON
Key concerns
Standford Hill (2022)
HMP/YOI Standford Hill, a Category D open prison, successfully maintained operations during the reporting period despite COVID-19, achieving low infection rates and a strong focus on prisoner rehabilitation, reflected in low reoffending. The IMB noted humane treatment of prisoners, dedicated healthcare, and an excellent record in providing work opportunities. Key concerns include poor performance by GFSL, inadequate technological support, and the deteriorating state of the prison's estate.
PRISON
Key concerns
Grendon (2023)
HMP Grendon, a Category B therapeutic prison, maintained its core function and safety despite an increase in self-harm and violence intelligence reports. However, the Board raised significant concerns including persistent staff shortages impacting therapy and education, an ongoing rat infestation, and an inadequate night sanitation system. Patient satisfaction with healthcare significantly declined, exacerbated by a critical lack of data, while delays in a fire safety project and the issue of men unable to move out of therapy caused further disruption.
PRISON
Key concerns
IMB Recommendations (77) — showing 50 strongest matches
Cookham Wood (2021)
When will the YCS allow full-time education to resume for boys in Cookham Wood so they can return to pathway-based education ?
HMPPS
Lowdham Grange (2024)
What action is being taken to address HM Coroner’s stated concerns, including: a failure to investigate whether anything could have been done to prevent the deaths; failure to seek any lessons from the deaths; failure to implement any findings of the Prisons and Probation Ombudsman (PPO); and the failure to inform staff of policies and procedures relating to the deaths, …
Governor / Director
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Governor / Director
London STHF (2024)
The Board stopped receiving Safer Detention Reports in July 2023 and despite many requests, these have not been forthcoming. This means that we do not have access to the data to enable us to monitor Suicide and Self Harm Warning Forms, Vulnerable Adult Warning Forms and Use of Force. After repeated requests at every Board meeting, we were eventually told …
Other
Doncaster 2019 – (2019)
All lessons to be learnt from the findings of internal investigations and the reports of the PPO into deaths in custody to be actioned.
Governor / Director
Dartmoor (2023)
Can the implementation of the Action Plan, and the monthly progress reports issued as a result of the recent report into the prison by HMIP Inspectors be shared regularly with the IMB?
Governor / Director
Oakwood (2025)
Can the Director facilitate the installation of IMB information noticeboards in the admissions area and on the induction wings to further inform and promote the work of the IMB?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
We request clarity on what remedies have been or are to be introduced to prevent this failure in the future.
Other
Dovegate (2025)
The Board asks that the Director ensures the culture of continuous improvement becomes permanently ingrained at Dovegate.
Governor / Director
Brinsford (2023)
The Board is fully aware of the difficult culture within Brinsford and fully aware of the attempts you have made to change it, to no avail. Improved supervision by middle managers and having experience in other establishments might be helpful.
Governor / Director
Brinsford (2023)
This year the standards coaching team were brought in to train and upskill officers, they also gave them the confidence to challenge prisoners. They have been instrumental in getting officers out of their comfort zone. We eagerly wait to see the improvements becoming part of the daily routine.
Governor / Director
Brinsford (2023)
Following the complete lockdown of the prison during the pandemic, the Board feels some officers became lax in fulfilling their duties, and many lacked the experience of a busy active prison and took the easy option where possible.
Governor / Director
Brinsford (2023)
The Board recognises that the senior leadership team are enthusiastic, talented and energised to take forward your ideas to improve prisoner outcomes; however the messages did not reach the officers who carry out these management decisions, or they failed to carry out the directions.
Governor / Director
Isle of Wight (2020)
The HMIP inspection identified four areas that required external support from HMPPS; the subsequent Independent Review of Progress (IRP) report noted that: ‘these were rejected and so no progress had been made’. The IRP visit in January 2020 noted improvement by local management but there was a lack of support from the Prison Service nationally – including in ensuring basic …
HMPPS
Featherstone (2020)
The restrictions introduced to deal with the COVID-19 pandemic have resulted in the cessation of education programmes, rehabilitation initiatives and many key worker contacts which are fundamental to the completion of sentence plans. While the Board understands the reasons for the constraints, they have an adverse impact on the life chances of prisoners and the achievement of a rehabilitative culture. …
HMPPS
Bedford (2020)
Learn the positive lessons of COVID-19 – for example, the importance of predictable regimes, smaller groups, more interaction, fewer drugs and regular contact with families.
Governor / Director
Bedford (2020)
Ensure that the decrease in prisoner-on-prisoner violence during the COVID-19 crisis is not used as an excuse to maintain lockdown conditions. Analyse all the lessons of the crisis and take actions accordingly.
HMPPS
Wealstun (2021)
Ensure that as prisons move out of lockdown a review is undertaken to identify any long-term effects on prisoners and plans are in place to address them (repeat area from 2019/2020 report).
HMPPS
Gartree (2021)
Will the Governor work with the Board to identify ways to continue to improve engagement between the Board and the SMT? The Board acknowledges that aspects of the working relationship have improved, but there are still occasions when the flow of information relies on us asking questions. We are keen to have key information provided so that we have the …
Governor / Director
Cookham Wood (2021)
However, the IMB believes this should be developed and implemented urgently.
HMPPS
Swaleside (2022)
The IMB is concerned at the occasional failure to be invited to serious incidents and planned moves to the CSRU and would appreciate the necessity for this to be reiterated to all senior staff.
Governor / Director
Hewell (2022)
Increase momentum on culture change to ensure staff are curious, proactive and engaged and do not accept the unacceptable; identify and decisively address people or process issues that are blocking change. Pathway planning and key work is core to the change and should be given priority in all but the direst of staffing situations.
Governor / Director
Haverigg (2022)
Thematic reviews carried out by members of the IMB open estate chairs’ group revealed differences between some prisons in a number of areas. The Board is concerned that apparent inconsistencies in these areas may cause confusion and, potentially, frustration when prisoners transfer between establishments: • application of the victim support levy • the number of prisoners being returned to closed …
HMPPS
Standford Hill (2023)
Will the Prison Service facilitate more formal sharing of best practice between Category D prisons?
HMPPS
Haverigg (2023)
the Board has not examined specific evidence to support or refute this feedback, but asks the Governor and senior managers to maintain careful and sustained oversight of this important area to ensure consistency.
Governor / Director
Huntercombe (2024)
When will the Prison Service ensure that all prisons follow the agreed procedures for all issues? The Board has reported on failures in prisoner property management and management of foreign national prisoners as two examples in this reporting year.
HMPPS
Hull (2024)
How will the prison service put systems in place to resolve these issues? The Board note that these same concerns were raised in our 2021/22 and 2022/23 reports with limited progress continuing to be observed by the Board in this area.
HMPPS
Cookham Wood (2024)
Will the Minister evaluate the potential for a better way of working in the English YOI estate?
Other
Wandsworth (2025)
In the past year, the IMB was not always informed of major incidents, particularly deaths in custody. Can you assure us that you will put a process in place to rectify this?
Governor / Director
Wandsworth (2025)
In the light of the UN issued to the prison and the subsequent recommendations made under the Action Plan, what are your priorities as the newly appointed Governor?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
We request that Care & Custody provide the IMB with a clear timeline and process for consulting with the IMB on the content and outcome of the review.
Other
Lowdham Grange (2025)
What is being done to ensure the mistakes and omissions highlighted in the recent Prevention of Future Deaths reports by the Coroner are not repeated?
Governor / Director
Channings Wood (2025)
What evidence can HMPPS point to that demonstrates that they do care and that things will indeed get better?
HMPPS
Werrington (2020)
Are there any positive changes for young people have been identified during the pandemic that can be implemented in the long term?
Governor / Director
Humber (2020)
The national leadership of the Prison Service has, in the opinion of the Board, hindered the ability of the prison to progress with the recovery process. They have been frustrated at the slow pace of recovery set out by national guidance from HMPPS, which has allowed little, if any room, for autonomy. The Board is of the opinion, in relation …
HMPPS
Hewell (2020)
The Board is often aware of a reliance on systems and processes in managing issues within Hewell, rather than a focus on robust problem solving and effective decision making. This tendency is demonstrated in the frequency with which ostensibly minor issues or concerns are allowed to escalate, with recourse to documentary systems – for example, the complaints or adjudication systems …
Governor / Director
Exeter (2020)
Will the Prison Service evaluate the impact of the COVID-19 pandemic on prison operation in order to learn lessons for the future and to retain those positive initiatives that have improved the lives and experiences for prisoners (for example, Purple Visits and streamed funeral services - paragraphs 5.5 and 7.4)?
HMPPS
Bedford (2020)
Learn the lessons of the importance of family contact, both face to face and virtual.
HMPPS
Yarl’s Wood (2021)
The Board recommends that, where practical, the centre gives the Board good notice of all subject multidisciplinary team meetings so that the Board has the opportunity to attend.
Governor / Director
Whitemoor (2021)
The Board strongly supports the establishment of the prison rehabilitation culture council and would encourage the Governor to continue the positive work she has begun to ensure that it is seen by prisoners as a significant force for the improvement of prison life in Whitemoor.
Governor / Director
Warren Hill (2021)
The Board also recognises that the prolonged lockdown has provided an opportunity to look at the regime at Warren Hill and hopes that the Governor will use this to implement positive changes.
Governor / Director
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: rebuilding the culture and the sense of collective responsibility in the communities which has been affected across so many of the activities that Grendon was able to provide pre-pandemic (see 5.3.4, 7.1.3 and 7.1.5)
Governor / Director
Chelmsford (2021)
To support the Governor and staff in making the changes and improvements highlighted by Her Majesty's Inspectorate of Prisons’ inspection in August 2021, and those noted by us.
HMPPS
Bristol (2021)
Please encourage HM Prison and Probation Service (HMPPS) and other visitors to the establishment to make contact with the Board. As independent volunteers carrying out a statutory role, we are a vital set of eyes and ears, and can provide valuable information and insights into the prison.
HMPPS
Nottingham (2022)
We hope that lessons learned during the lockdown period will be used to inform the organisation of the prison when the restrictions are lifted and that initiatives found to be beneficial can continue, so that the overall experience of prisoners is improved.
Governor / Director
Grendon (2022)
Continued progress on rebuilding culture and ethos on the communities (7.1.3).
Governor / Director
Bedford (2022)
As far as we are aware there have been no attempts to evaluate the effectiveness of the assessment, care in custody and teamwork (ACCT) process to understand whether it has achieved (or failed) its objective of supporting those at risk of self-harm.
HMPPS
South and West Short Term Holding Facilities 2023 -24 (2023)
The Board recommends that the NPM encourages its members to consider more co-ordination to monitor the total detention experience.
Other
South and West Short Term Holding Facilities 2023 -24 (2023)
The Board recommends you ensure the BF informs the IMB promptly when someone has been detained, so they can be interviewed by a Board member.
Governor / Director
South and West Short Term Holding Facilities 2023 -24 (2023)
The Board recommends you provide IMB members at Portsmouth Ferry Port with passes to enable them to carry out unannounced visits, in accordance with Part 7 of the STHF Rules, which sets out the responsibilities of the IMB.
Governor / Director
Health Investigations (2)
An independent review of the Independent Investigations for Mental Health … — Rec 8
It is recommended that the IIGC should develop measures to demonstrate the impact and outcomes of the Independent Investigation process, with particular regard to; learning, service improvement, policy development and the experience of all affected families and carers.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 6
It is recommended that the IIGC should alert the National Quality Board and the Quality Assurance Group of the complexities and challenges of sharing learning and implementing improvement across the wider systems and with those partners identified by recommendation four.
north_east_yorkshire
Article 2 Learning Points (12)
— LP 22
We recommend that steps are taken at HMP Pentonville to share findings of future internal investigations, whether these investigations are formal or otherwise, with the relevant audience(s). We would encourage the use of face‐to‐face fora for this, rather than simply circulating investigation reports. This approach should help enhance the feeling …
The Governor
Accepted
— LP 1
If it has not already done so, HMP Whitemoor may wish to consider the benefits to be obtained from reviewing internal procedures and guidance for the management, recording and investigation under PSOs 1300, 2700 and 2750 of both prisoner on prisoner assaults and unexplained injuries. It may also be considered …
HMP Whitemoor
Accepted
— LP 7
I recommend that NOMS reviews the guidance to establishments about action following life-threatening incidents of self-harm to ensure that it makes clear that evidence must be preserved.
NOMS
— LP 17
The prison should develop a robust method for investigating serious untoward incidents using root cause analysis methodology.
HMP Altcourse
Partially Accepted
— LP 21
We recommend that following serious incidents, measures are taken at HMP Pentonville to ensure that support is provided, and information is actively disseminated, beyond the day of the incident itself. Responsibility for how this support is provided and how information is disseminated should be agreed at the post‐incident hot debrief …
The Governor
Accepted
— LP 15
We recommend the ongoing use of the record‐keeping audit tool being used on HMP Pentonville’s Healthcare unit, whilst ensuring that it continues to make a tangible difference and informs decision‐making, rather than being seen as a paper‐filling exercise. Showing staff exactly how it is making a difference should further encourage …
PPG
Accepted
— LP 14
In addition we recommend that the prison should take a proactive role in providing necessary written information so that, in general, the investigation is in the position of reviewing the documentation and deciding which of that supplied is relevant rather than trying to determine what documents may be available that …
HMPPS
Accepted
— LP 13
We recommend that a dedicated liaison officer be appointed for any Independent Investigation. The person appointed should report directly to the Governor for the duties performed in this role and should be allowed sufficient time away from normal duties to be able to perform to an acceptable standard and to …
HMPPS
Accepted
— LP 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
HMP Whitemoor
Accepted
— LP W
A clearer policy should be developed about the nature and extent of investigations which should take place following incidents of self-harm, so that prisons know when a local investigation within the prison is likely to be adequate, when an internal Prison Service investigation by the Area Manager is needed and …
HMPPS
— LP 12
We recommend that clearer guidance is produced on what kind of immediate internal inquiry should be undertaken following acts of serious self-harm, what evidence should be collated and retained and what form of action planning should be set in place as a result.
HMPPS
Partially Accepted
— LP 7
We recommend that Prison Officers E and F, Nurse 3 and the Night Orderly Officer, Mr M, should be commended for their diligence in seeking to save CR.
HMPPS
Accepted
LGO / SPSO Decisions (5)
21-018-399 — Leeds City Council
Summary: We will not investigate Ms M’s complaint about the actions of a health visitor, who was providing a service on behalf of the Council. An investigation by the Local Government and Social Care Ombudsman is unlikely to add to the outcomes of previous investigations by other organisations.
LGO (Local Government & …
Other Categories
Apr 2022
25-002-918 — Greater London Authority
Summary: We will not investigate Mr X’s complaint that the Authority did not commission research into the aging process. This is because we cannot achieve the outcome Mr X wants.
LGO (Local Government & …
Other Categories
Jun 2025
201900021 — University of Glasgow
Ms C, a postgraduate student, complained that she had paid for classes and seminars which had been cancelled due to industrial action. We found that the University had taken appropriate steps to minimise the academic impact of the industrial action by giving students advance notice of the industrial action and …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
201808095 — University of Glasgow
Mr C was required to complete three school placements as part of his secondary teaching course. Mr C complained that the university failed to provide him with appropriate support during his course and that, after he was deemed to have failed, they did not follow their normal procedure. He was …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
22-004-281 — St James' Catholic High School, Cheadle
Summary: Miss Z complained the Independent Admissions Appeals Panel failed to properly consider her appeal for a place at the School for her child, Y. There was no fault in the way the Panel considered Miss Z’s appeal and reached its decision.
LGO (Local Government & …
Education
Not Upheld
Nov 2022