No person-centred care
317 items
2 sources
Failure to ensure the provision of truly person-centred care that meets individual needs, preferences, and promotes dignity.
Cross-Source Insight
No person-centred care has been flagged across 2 independent accountability sources:
80 inquiry recs
237 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (80)
BRIS-1 — Ensure patient involvement in all treatment and care decisions
Recommendation: In a patient-centred healthcare service patients must be involved, wherever possible, in decisions about their treatment and care.
Unknown
BRIS-10 — Provide NHS tape-recording facilities for patients to record healthcare discussions
Recommendation: Tape-recording facilities should be provided by the NHS to enable patients, should they so wish, to make a tape recording of a discussion with a healthcare professional when a diagnosis, course of treatment, or prognosis is being discussed.
Unknown
BRIS-102 — Ensure patients are informed about innovative procedures and clinician experience
Recommendation: Patients are always entitled to know the extent to which a procedure which they are about to undergo is innovative or experimental. They are also entitled to be informed about the experience of the clinician who is to carry out …
Unknown
BRIS-11 — NHS employers must ensure staff allow patients time for questions
Recommendation: Patients should always be given the opportunity and time to ask questions about what they are told, to seek clarification and to ask for more information. It must be the responsibility of employers in the NHS to ensure that the …
Unknown
BRIS-12 — Provide patients with information enabling active participation in their care decisions.
Recommendation: Patients must be given such information as enables them to participate in their care.
Unknown
BRIS-125 — Formulate national clinical standards from patient-centred perspective, based on best evidence.
Recommendation: National standards of clinical care should reflect the commitment to patient-centred care and thus in future be formulated from the perspective of the patient. The standards should address the quality of care that a patient with a given illness or …
Unknown
BRIS-13 — Provide patients with pre-procedure explanation and post-procedure review opportunity.
Recommendation: Before embarking on any procedure, patients should be given an explanation of what is going to happen and, after the procedure, should have the opportunity to review what has happened.
Unknown
BRIS-14 — Provide support for patients experiencing anxiety due to increased medical knowledge
Recommendation: Patients should be supported in dealing with the additional anxiety sometimes created by greater knowledge.
Unknown
BRIS-15 — Inform patients they can have a chosen person present when receiving information
Recommendation: Patients should be told that they may have another person of their choosing present when receiving information about a diagnosis or a procedure.
Unknown
BRIS-157 — Embed public and patient perspectives into all NHS healthcare decision-making structures
Recommendation: The involvement of the public in the NHS must be embedded in its structures: the perspectives of patients and of the public must be heard and taken into account wherever decisions affecting the provision of healthcare are made.
Unknown
BRIS-158 — Require non-NHS regulatory bodies to involve the public in healthcare decisions
Recommendation: Organisations which are not part of the NHS but have an impact on it, such as Royal Colleges, the GMC, the Nursing and Midwifery Council and the body responsible for regulating the professions allied to medicine, must involve the public …
Unknown
BRIS-16 — Empower patients to decline information, requiring skilled healthcare professional communication
Recommendation: Patients should be given the sense of freedom to indicate when they do not want any (or more) information: this requires skill and understanding from healthcare professionals.
Unknown
BRIS-160 — Focus public involvement on NHS service development, delivery, safety, and quality regulation
Recommendation: The public’s involvement in the NHS should particularly be focused on the development and planning of healthcare services and on the operation and delivery of healthcare services, including the regulation of safety and quality, the competence of healthcare professionals, and …
Unknown
BRIS-161 — Ensure Patients' Forums and Councils include wider public, not just patient groups
Recommendation: Proposals to establish Patients’ Forums and Patients’ Councils must allow for the involvement of the wider public and not be limited only to patients or to patients’ groups. They must be seen as an addition to the process of involving …
Unknown
BRIS-187 — Recognise parents as experts and fully involve them in their children's healthcare
Recommendation: Parents should ordinarily be recognised as experts in the care of their children, and when their children are in need of healthcare, parents should ordinarily be fully involved in that care.
Unknown
BRIS-188 — Value and incorporate parents' knowledge of very young children into care
Recommendation: Parents of very young children have particular knowledge of their child. This knowledge must be valued and taken into account in the process of caring for the child, unless there is good reason to do otherwise.
Unknown
BRIS-189 — Answer children's questions about their care truthfully and clearly
Recommendation: Children’s questions about their care must be answered truthfully and clearly.
Unknown
BRIS-190 — Mandate specific communication skills training for professionals caring for children and parents
Recommendation: Healthcare professionals intending to care for children should be trained in the particular skills necessary to communicate with parents and with children.
Unknown
BRIS-191 — Require healthcare professionals to be honest with parents about child's condition
Recommendation: Healthcare professionals should be honest and truthful with parents in discussing their child’s condition, possible treatment and the possible outcome.
Unknown
BRIS-2 — Integrate patient-professional partnership principles into all healthcare professional education and training
Recommendation: The education and training of all healthcare professionals should be imbued with the idea of partnership between the healthcare professional and the patient.
Unknown
BRIS-20 — Establish comprehensive counselling and support services as integral to patient care
Recommendation: The provision of counselling and support should be regarded as an integral part of a patient’s care. All hospital trusts should have a well-developed system and a well-trained group of professionals whose task it is to provide this type of …
Unknown
BRIS-24 — Treat patient consent as an ongoing process, not a single signature event
Recommendation: The process of informing the patient, and obtaining consent to a course of treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient’s signature on a form.
Unknown
BRIS-25 — Extend consent process to all clinical procedures involving touching, focusing on communication
Recommendation: The process of consent should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication.
Unknown
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
BRIS-3 — Adopt patient-professional partnership model across all NHS healthcare settings
Recommendation: The notion of partnership between the healthcare professional and the patient, whereby the patient and the professional meet as equals with different expertise, must be adopted by healthcare professionals in all parts of the NHS, including healthcare professionals in hospitals.
Unknown
BRIS-4 — Provide treatment and care information in varied forms, stages, and reinforced
Recommendation: Information about treatment and care should be given in a variety of forms, be given in stages and be reinforced over time.
Unknown
BRIS-5 — Tailor patient information to individual needs, circumstances, and wishes
Recommendation: Information should be tailored to the needs, circumstances and wishes of the individual.
Unknown
BRIS-57 — Prioritise non-clinical skills in healthcare professional education and development
Recommendation: Greater priority than at present should be given to non-clinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals: (cid:2) skills in communicating with patients and with colleagues; (cid:2) education about …
Unknown
BRIS-59 — Make communication skills education essential for all healthcare professionals
Recommendation: Education in communication skills must be an essential part of the education of all healthcare professionals. Communication skills include the ability to engage with patients on an emotional level, to listen, to assess how much information a patient wants to …
Unknown
BRIS-6 — Provide evidence-based patient information in a comprehensible summary format
Recommendation: Information should be based on the current available evidence and include a summary of the evidence and data, in a form which is comprehensible to patients.
Unknown
BRIS-60 — Include inter-professional engagement and respect in communication skills training
Recommendation: Communication skills must also include the ability to engage with and respect the views of fellow healthcare professionals.
Unknown
BRIS-7 — Regularly update and pilot patient information materials with active patient involvement
Recommendation: Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.
Unknown
BRIS-8 — NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Recommendation: The NHS Modernisation Agency should make the improvement of the quality of information for patients a priority. In relation to the content and the dissemination of information for patients, the Agency should identify and promote good practice throughout the NHS. …
Unknown
BRIS-9 — Develop kitemarking system for reliable internet health information guidance for public
Recommendation: The public should receive guidance on those sources of information about health and healthcare on the Internet which are reliable and of good quality: a kitemarking system should be developed.
Unknown
2 — Patient-focused correspondence
Recommendation: We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than …
Gov response: Accepted. The Academy of Medical Royal Colleges updated their 2018 guidance 'Please write to me' in light of this recommendation. Guidance emphasises writing directly to patients, copying in GPs, using clear language. NHS England is …
Accepted
No update 2+ yrs
3 — Explaining independent sector differences
Recommendation: We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised is explained clearly to patients, so that they understand how the engagement of …
Gov response: Accepted. CQC now requires independent healthcare providers to ensure patients understand these arrangements as part of their registration conditions. The Private Healthcare Information Network (PHIN) also provides comparative information. Independent providers should explain consultant engagement …
Accepted
No update 2+ yrs
4 — Reflection period for consent
Recommendation: We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. The GMC should monitor this as part of …
Gov response: Accepted in principle. GMC guidance on consent (updated 2020) already emphasises patients should have time to consider information before making decisions. The guidance states patients should not be placed under pressure to make decisions quickly. …
Accepted in Part
No update 2+ yrs
6a — Communicating complaint escalation
Recommendation: We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and the independent sector.
Gov response: Accepted. NHS complaints processes now more clearly signpost to Parliamentary and Health Service Ombudsman. Independent Healthcare Providers Network has agreed to ensure members inform patients about Independent Sector Complaints Adjudication Service (ISCAS). CQC monitors complaints …
Accepted
No update 2+ yrs
6b — Mandatory independent complaint resolution
Recommendation: We recommend that all private patients should have the right to mandatory independent resolution of their complaint.
Gov response: Accepted in principle. Government supports principle but further work needed on implementation mechanism. ISCAS membership has grown significantly since the inquiry. Government is considering whether legislative change is needed to make independent adjudication mandatory for …
Accepted in Part
No update 2+ yrs
IHRD-10 — Age-Appropriate Hospital Settings
Recommendation: Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes.
Accepted
Delivered
IHRD-16 — Bedside Display of Responsible Staff
Recommendation: The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all can know who is in charge and responsible.
Gov response: Name boards implemented at bedsides in children's wards across Trusts.
Accepted
Delivered
IHRD-21 — Nurse Attendance at Clinical Interactions
Recommendation: The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.
Gov response: Guidance issued on nurse attendance during clinical interactions with child patients.
Accepted
No update 2+ yrs
IHRD-22 — Parental Knowledge in Care Plans
Recommendation: Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.
Gov response: Parental involvement in care planning promoted through policy and training.
Accepted
Delivered
IHRD-23 — Care Plan Availability at Bedside
Recommendation: The care plan should be available at the bed and the reasons for any change in treatment should be recorded.
Gov response: Care plans made available at bedside. Documentation standards updated.
Accepted
Delivered
IHRD-26 — Recording Clinical Discussions
Recommendation: Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.
Gov response: Documentation standards updated to require recording of clinical discussions and handovers.
Accepted
Delivered
IHRD-28 — Informed Consent Documentation
Recommendation: Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.
Gov response: Informed consent processes reviewed and updated.
Accepted
Delivered
F116 — Support for complainants
Recommendation: Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support.
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
F117 — Support for complainants
Recommendation: A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.
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
F129 — Ensuring assessment and enforcement of fundamental standards through contracts
Recommendation: In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental safety and quality standards are maintained. This requires close engagement …
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
F134 — Role of commissioners in provision of support for complainants
Recommendation: Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.
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
F135 — Public accountability of commissioners and public engagement
Recommendation: Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should be a membership system whereby eligible members of the public …
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
F185 — Focus on culture of caring
Recommendation: There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: Selection 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
F187 — Practical hands-on training and experience
Recommendation: There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct care …
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
F190 — National standards
Recommendation: There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of compassionate care.
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
F191 — Recruitment for values and commitment
Recommendation: Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements.
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
F195 — Nurse leadership
Recommendation: Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about the care plans relating to every …
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
F196 — Nurse leadership
Recommendation: The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and, in particular, to the priority to be accorded to dignity and respect, and their acquisition 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
F199 — Key nurses
Recommendation: Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on duty should, whenever possible, be present at every interaction between …
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
F2 — Putting the patient first
Recommendation: The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: A common set of core values and standards shared throughout the system; Leadership …
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
F200 — Key nurses
Recommendation: Consideration should be given to the creation of a status of Registered Older Person's Nurse.
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
F236 — Identification of who is responsible for the patient
Recommendation: Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who is in overall charge of a patient's care.
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
F237 — Teamwork
Recommendation: There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance staff, and catering staff also needs to be recognised and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F238 — Communication with and about patients
Recommendation: Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff need to be enabled to interact constructively, in a helpful and friendly fashion, with patients and visitors. Where …
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
F239 — Continuing responsibility for care
Recommendation: The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time …
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
F4 — Clarity of values and principles
Recommendation: The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by …
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
F58 — Care Quality Commission independence strategy and culture
Recommendation: Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a 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
F6 — Clarity of values and principles
Recommendation: The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance.
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
F62 — Improved patient focus
Recommendation: For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
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
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
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
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(4) — Define specific duties for Children's Complaints Officers, prioritising child's best interests
Recommendation: Amongst the duties of the Children's Complaints Officer should be: (a) to act in the best interests of the child; (b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child; …
Unknown
WATE-(5) — Ensure all decisions regarding abused children are made in their best interests
Recommendation: Any decision about the future of a child who is alleged to have been abused should be made in that child's best interests. In particular, the child should not be transferred to another placement unless it is in the child's …
Unknown
AS-6 — Informing Detainees of Rights
Recommendation: All detainees should be clearly informed of their rights and obligations as soon as is practicable upon arrival at any detention facility. As a minimum this should include informing the detainee as to the reason(s) for his detention and explaining, …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-7 — Strip-Search Safeguards
Recommendation: Appropriate measures should be taken to ensure that minimum safeguards are in place where a detainee is to be strip-searched. These include informing a detainee as to the necessity for the strip-search and requesting his/her co-operation. Those conducting a strip-search …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-8 — Interpreter Availability
Recommendation: There should be an appropriate review of all current, relevant policy and procedures to ensure that a sufficient number of suitably trained interpreters are readily available and on hand during all aspects of prisoner detainee handling, including all forms of …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
COVID-M3.9 — Standardised Advance Care Planning
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for …
Gov response: No formal response published by this government.
Unknown
R10 — CDI patient information
Recommendation: Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.
Gov response: Section 4.2 of the Scottish Government's response highlights initiatives promoting person-centred care, including the 'Must Do with Me' elements, which emphasize 'what information do you need?' and patient involvement in decisions. The response also details …
Accepted
R11 — CDI severity awareness
Recommendation: Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, particularly in the elderly.
Gov response: Section 4.2 of the Scottish Government's response describes initiatives to improve patient and family communication. The Person-centred Health and Care Collaborative developed "Must Do with Me" elements, including "what information do you need?", to ensure …
Accepted
R12 — CDI infection control advice
Recommendation: Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions.
Gov response: Section 4.2 of the Scottish Government's response highlights initiatives to improve patient and family communication. The Person-centred Health and Care Collaborative's "Must Do with Me" elements include ensuring patients receive the information they need, which …
Accepted
R21 — Nursing staff for relatives
Recommendation: Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.
Gov response: Section 4.2 of the Scottish Government's response addresses this by highlighting the Participation Standard, which the Scottish Health Council uses to monitor and drive improvement in how people are involved in the NHS, including communication. …
Accepted
PFD Reports (237) — showing 100 most recent
Bonita Cleary
Concerns: A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Pending
David Dugdale
Concerns: Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.
Overdue
Suzanne Pemberton
Concerns: The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.
Response: East Suffolk and North Essex NHS Foundation Trust has undertaken a project to ensure all relevant ward areas receive consistent training related to dietetic care planning. They are also carrying …
Responded
Izzah Ali
Concerns: Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.
Response: The Trust has updated ED and paediatric documentation and made 'What is in the bottle?' a standard inquiry across services to improve clarity on infant feeding. They have also enhanced …
Response: Minor Injuries Unit staff have been instructed to specifically inquire about the contents of bottles if nutrition is a concern. Staff have also been reminded to weigh children on each …
Response: Cornwall Council has secured funding to rewrite its 'Essential Guide to feeding and caring for your baby' and the digital version has already been updated with translated versions. They plan …
Responded
Mark Vidler
Concerns: Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.
Response: Kent and Medway NHS Mental Health Trust has delivered refresher training focusing on patient-centred care and introduced regular service user/carer feedback. They are revising their Rapid Response Standard Operating Procedure …
Responded
Lynsey Dearden
Concerns: A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for appointments or initial assessments.
Response: NHS England has shared draft national guidance, the Personalised Care Framework, with systems for early adoption, which sets out core principles for care plans, therapeutic relationships, and access to secondary …
Response: The Trust has implemented new Standard Operating Procedures (SOPs) for patient contact and appointments, mandating initial contact within 48 hours and assessment within 14 days of referral. A new process …
Responded
Suzanne Ellerby
Concerns: A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in essential follow-up.
Response: NHS England has drafted the Personalised Care Framework (PCF) guidance, which sets out specific recommendations for transferring and receiving services to ensure effective care transitions for mental health patients. This …
Response: The Department for Health and Social Care acknowledges the concerns and, following enquiries with NHS England, highlights that NHS England has developed draft Personalised Care Framework (PCF) guidance. This guidance …
Overdue
Amber Walker
Concerns: Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Response: The Department of Health and Social Care noted the concerns, referencing existing NICE guidance on epilepsies and the Clive Treacey Checklist for systematic SUDEP risk assessment. It also explained that …
Responded
William King
Concerns: Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a risk of recurrence.
Response: The Royal College of Surgeons of England plans to update its guidance on consent, develop a practical toolkit and a short set of principles on shared decision-making by Spring 2026, …
Response: The Association of Anaesthetists and Royal College of Anaesthetists are shortly publishing a Good Practice guide on Rapid Sequence Induction (RSI) that addresses NG tube considerations, and will update their …
Response: The Trust accepts failures in explaining risks and documenting discussions, and plans to introduce a new electronic form in the New Year. This form will act as an aide-memoire for …
Responded
Naomi Aylott
Concerns: The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement in remote care.
Response: The Trust has remedied a data capture issue for carer information, with the data now captured on their visualisation platform, and is achieving greater alignment in the Carers function post-merger.
Responded
Kore Padgett
Concerns: There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.
Responded
Jacob Wooderson
Concerns: Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD patients may forget.
Responded
Myles Scriven
Concerns: GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a lack of appropriate secondary care referral.
Responded
Patricia Heaviside
Concerns: The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of Liberty Safeguards (DoLS) assessments for residents lacking mental capacity.
Overdue
Andrew Connolly
Concerns: GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these situations.
Responded
Ann Caldicott
Concerns: Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.
Responded
Esther Byrne
Concerns: Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.
Responded
Callum Hargreaves
Concerns: The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.
Responded
Callum Hargreaves
Concerns: The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, and record-keeping was deficient.
Responded
Julie Beasley
Concerns: Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of professional curiosity and poor record-keeping also contributed.
Responded
Robert Smith
Concerns: Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.
Responded
Marina Waldron
Concerns: During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.
Responded
Joseph Powell
Concerns: GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Responded
Rose Harfleet
Concerns: The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning Disability Liaison Nurse, leading to poor care.
Responded
Mark Fernandez
Concerns: Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term carers and social services.
Responded
William Green
Concerns: The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to take, including for those without capacity.
Responded
Charlie Marriage
Concerns: Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency medication access.
Responded
Fahmida Khanam
Concerns: A doctor treated a close relative, breaching the cardinal principle of medical ethics.
Responded
Robert McGowan
Concerns: Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially treated bacterial endocarditis.
Responded
Susan Evans
Concerns: Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed to the patient's death.
Responded
David Stables
Concerns: There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.
Responded
Dean Ford
Concerns: Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments for unaccepted patients are not audited, creating a safety net gap.
Responded
Mnayea Al Basman
Concerns: Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. Poor record-keeping and absence of an internal investigation were also identified.
Responded
Kevin Ince
Concerns: There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.
Responded
Richard Brookes
Concerns: DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in a lack of clear communication and exacerbating the patient's paranoia about the money.
Responded
Yemisi Cielto-Opaleye
Concerns: Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.
Responded
Anne Taylor
Concerns: A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.
Responded
Jyoti Rao
Concerns: The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.
Responded
Beverley Stanisauskis
Concerns: Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability team.
Responded
Stephen Lindsay
Concerns: Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks future deaths as patients may not receive necessary support, leading to crises.
Responded
Benjamin Faux
Concerns: The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and ensuring follow-through on study suspensions, and staff underestimated mental health risks.
Responded
Debra Bates
Concerns: A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.
Responded
Alan Lee
Concerns: Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt life-saving techniques.
Overdue
Sewa Chaddha
Concerns: Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and posed a safety risk.
Responded
Miriam Stone
Concerns: Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy to manage or avoid admissions at these times.
Responded
Emmanuel Ladapo
Concerns: Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical deterioration, despite prior similar omissions.
Overdue
Joshua Delaney
Concerns: GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future deaths.
Responded
Carole Mather
Concerns: A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying legal frameworks for individuals with chronic alcohol dependence, risking their protection.
Responded
Mark Kinzley
Concerns: Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite a history of self-harm and deteriorating mental state contributed to the death of a vulnerable adult.
Overdue
Regina Ademiluyi
Concerns: Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little meaningful reflection or remediation followed her death.
Responded
Sylvia Nash
Concerns: Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Responded
Karmchand Gulzar
Concerns: Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.
Responded
Catherine Jones
Concerns: Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was not a formal system, risking future harm.
Responded
Margaret Heal
Concerns: A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.
Overdue
John Lee
Concerns: Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.
Responded
Lee Bowman
Concerns: Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual daily contact.
Responded
Claire Twinn
Concerns: Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a critically delayed radiological report.
Responded
Mark McKessy
Concerns: Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.
Responded
Donna Levy
Concerns: Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation decision overlooked wider health problems.
Responded
Kirsty Taylor
Concerns: Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains ineffective, and the Personality Disorder Pathway development is too slow.
Responded
Elliott Harratt
Concerns: Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn babies.
Responded
David Wilson
Concerns: The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical history, omitted the risk of death, and was signed while sedated.
Responded
Mark Ravensdale
Concerns: Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.
Responded
Mojeri Adeleye
Concerns: There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.
Responded
Callum Wong
Concerns: Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial non-medical support.
Overdue
Keith Hodson
Concerns: Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical priority. Delays in incident reporting and family communication were also noted.
Responded
Maureen Dick
Concerns: Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, delaying diagnosis. There is also no mandatory training for clinical staff on pressure ulcers.
Overdue
Sophie Williams
Concerns: Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, inadequate staff training, poor assessment protocols, and insufficient mental health support.
Responded
Eric Huber
Concerns: Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and multi-disciplinary discussions, compromised his care.
Overdue
Lucy Jones
Concerns: Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.
Responded
Terri Malone
Concerns: An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and voicemail, despite long waiting lists, without assessing their current situation or input from other agencies.
Responded
Clifford Rose
Concerns: Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments should be conducted face-to-face, ideally involving family members, for accurate needs identification.
Responded
Hollie Richardson
Concerns: Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware of actions to mitigate thromboembolic risks.
Overdue
Chelsea Mooney
Concerns: The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, and self-harm incidents lacked debriefs to inform future risk assessments.
Responded
Allan Waddup
Concerns: Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person follow-up before discharge, and urgent weekend referrals were not triaged.
Responded
Mathew Moore
Concerns: An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of concerns. There was also a lack of follow-up for this remote prescribing.
Responded
Malcom Garrett
Concerns: There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.
Overdue
Malcolm Garrett
Concerns: There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.
Responded
Locksley Burton
Concerns: Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.
Responded
Darren Jones
Concerns: Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care training.
Responded
Kieran Crimmins
Concerns: Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.
Overdue
Gordon Hendley
Concerns: Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also hindered family advocacy.
Overdue
Anthony McLellan
Concerns: Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, including the higher suicide prevalence for autistic individuals. Staff lacked understanding of specialist team access.
Overdue
Gwynne Samuel
Concerns: The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly patient. A 12-hour delay in ambulance arrival for a serious condition contributed to the patient's death, highlighting systemic risks.
Responded
Daniel Ludlam
Concerns: The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
Overdue
Esma Guzel
Concerns: The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.
Responded
Marjorie Grayson
Concerns: The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.
Responded
Spencer Barr
Concerns: Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information sharing between multiple care agencies for a high-risk patient.
Overdue
Cynthia Finlay
Concerns: There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.
Overdue
Vilem Bock
Concerns: While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary care.
Responded
Zoe Zaremba
Concerns: Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.
Responded
Millie-Rae Needham
Concerns: Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. "Normal birth" language on checklists is also concerning.
Overdue
Natalie Turner
Concerns: GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.
Responded
Emily Caldicott
Concerns: Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.
Overdue
Billy Longshaw
Concerns: The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.
Overdue
Neil Hickman
Concerns: Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.
Responded
Stephanie Moyce
Concerns: Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.
Overdue
Matthew McManus
Concerns: An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.
Responded
Benjamin Stroud
Concerns: A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
Overdue
Terence Talbot
Concerns: Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient to attend in person for benefits.
Responded