No person-centred care
Failure to ensure the provision of truly person-centred care that meets individual needs, preferences, and promotes dignity.
1,232 items
14 sources
9 inquiries
Source spread
Where this theme appears
No person-centred care has been flagged across 14 independent accountability sources:
80 inquiry recs
237 PFD reports
122 committee recs
349 CQC actions
2 ICIBI recs
48 PPO recs
2 PHSO recs
35 IMB reports
75 IMB recs
3 Article 2 learning points
2 detention investigation recs
215 PHSO decisions
60 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 (80) — showing 50 strongest matches
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
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-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-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-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-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-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
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
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
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
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
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
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-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-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-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-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-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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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-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-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-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-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-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-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-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-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-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-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-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-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-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
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
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
PFD Reports (237) — showing 50 strongest matches
Ronald Sherlock
Concerns: Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.
Overdue
Rosa Anderson
Concerns: The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Response (Aintree University Hospital): Aintree University Hospital has implemented a discharge advice sheet for laparoscopic procedures and is providing generic leaflets for all discharged patients, with specialties developing individualized discharge information sheets by March …
Responded
Cynthia Fretwell
Concerns: The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication between staff and doctors.
Response (Hama Medical Centre): Hama Medical Centre has updated its Mental Capacity Act 2005 policy and updated its Telephone Consultation Protocol, in addition to discussing the Mental Capacity Act during medical meetings. They have …
Responded
Sandra Wordingham
Concerns: A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Response (Springbank Nursing Home): Springbank Nursing Home has produced a protocol for managing unconscious residents, including training for staff, clearer risk assessments, and mandatory summoning of emergency services in cases of doubt. The protocol …
Responded
Adrian Johnson
Concerns: The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
Response (HM Prison and Probation Service): NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject …
Overdue
Pauline Meredith
Concerns: Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Response (Browning Street Surgery): The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health …
Overdue
Ricky Anderson
Concerns: Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.
Overdue
Yousef Shokri-Gharab
Concerns: An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies …
Responded
Maureen Leaver
Concerns: Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.
Overdue
Jack Lynn
Concerns: The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Response (Nightingales Home Help Service): Nightingales Home Help Service will encourage clients to have medication charts and has advised staff to review their medication policy. They also provided a Safe Handling of Medication course for …
Responded
Andre Matei
Concerns: The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.
Response: The Department of Health acknowledges the coroner's concerns and states that NICE guidance addresses the use of interpreters. The Department will ensure the coroner's concerns are brought to NICE's attention …
Responded
Phyllis Barnes
Concerns: A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.
Overdue
Beryl French
Concerns: Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Response (Life Style Care): Life Style Care has provided updated training on DNACPR forms to staff across its remaining homes. An End of Life care plan has been piloted in 3 homes and is …
Responded
Frank Pope
Concerns: There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Response (Whittington Health NHS): The Trust will send a communication to all GPs via the GP Bulletin to remind them to include any information with regard to vulnerable patients or patients who lack capacity …
Overdue
Keiran Toman
Concerns: Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.
Overdue
Simon Haines
Concerns: There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.
Overdue
John Thorpe
Concerns: The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.
Overdue
Clare Cooper
Concerns: The report identifies poor GP documentation, a lack of robust assessment of presenting signs and symptoms, and a lack of routine vital sign monitoring. There were also concerns about the recognition, assessment, and management of electrolyte abnormalities.
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides information on its role and remit, and references existing guidance and resources related to the concerns raised regarding referral letters and communication with …
Response (Surrey Borders Partnership NHS): The Trust has revised its referral form to improve the quality of information GPs provide, including asking for more detail and highlighting the need to exclude organic causes of weight …
Response (Royal College of Psychiatrist): The Royal College of Psychiatrists agrees with the need for better EDS proformas. They highlight concerns about risk assessment in psychiatry and the need for eating disorder specialists with adequate …
Response (Woodlands Surgery): The surgery will ensure all consultations are fully documented in patient notes and proper assessments are conducted. All GPs will complete the BMJ online learning e-module on hyponatraemia. A consultant …
Responded
Gillian Crossley
Concerns: Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.
Overdue
James Clarke
Concerns: Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only theoretical training without practical application.
Response (CQC): The CQC will note the report and use it to inform the next inspection of Complete Care Services, focusing on their processes and training provision. They are also implementing new …
Responded
Gloria Foster
Concerns: Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management of communication channels with closed providers created risks.
Response (CQC): The CQC acknowledges the concerns and explains its role in regulating care providers. They note that the Local Authority is responsible for managing communication lines when a provider closes and …
Overdue
Nicholas Megginson
Concerns: Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.
Overdue
Clive Turner
Concerns: Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service reviewed the delayed response, implemented a new clinical support desk for early triage of calls, staffed by paramedics and nurses, using the Manchester Triage System. This …
Responded
George Palmer
Concerns: Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.
Response (Surrey and Borders Partnership NHS Trust): The Trust reviewed and reinforced procedures for sharing information with new service providers when patients relocate, including requesting GP details and sending discharge notifications. They have also logged the issues …
Responded
Leonard Hudson
Concerns: Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.
Overdue
Dorothy Clarkson
Concerns: Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
Overdue
Christopher Davies
Concerns: Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
Overdue
John Andrews
Concerns: Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.
Overdue
Chloe Siokos
Concerns: Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting continuity of care.
Overdue
George Vickery
Concerns: The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.
Overdue
Mary Fenton
Concerns: The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack of facilities for echocardiograms after hours, shortages of Isoprenaline, and failures in assessing the patient's mental capacity and obtaining consent to treatment.
Response (Department of Health): The Department of Health acknowledges the concerns about shortages of Isoprenaline and outlines the complexity of pharmaceutical supply chains. They note that Isoprenaline injection is unlicensed in the UK, but …
Response (Tameside Hospital): The trust has updated its DNACPR policy, stressed the importance of communication, reminded clinicians of relevant policies, and advised them to seek refresher training; cardiology staff have been instructed by …
Responded
Polly Carpenter
Concerns: The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.
Response (Devon Partnership NHS Trust): Level 2 observation forms are stored for two years, and uploaded if an incident occurs. Level 3 observation levels are entered straight on to the RiO progress notes. Revised documentation …
Responded
Barry Horrocks
Concerns: A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.
Overdue
Colin Ireland
Concerns: Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.
Overdue
Roseanne Cooke
Concerns: Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Response (5 Borough Partnership NHS): The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity …
Responded
Mark Hancock
Concerns: The coroner identified poor record-keeping, a lack of documented risk assessment, and an inappropriate environment for sensitive discussions with the deceased. There was also no procedure for managing situations where a patient requires admission but no bed is available.
Overdue
Elsie Mallalieu
Concerns: Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Response (Tameside Hospital NHS Trust): Tameside Hospital NHS Trust provided training to doctors in the Orthopaedic Department regarding patient transfer protocols and the involvement of senior medical staff. The training also forms part of the …
Responded
Tracey Bannister
Concerns: Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.
Response (Walsall Healthcare NHS Trust): Walsall Healthcare NHS Trust revised the ERCP discharge leaflet to include clear instructions for patients to contact the department where surgery was performed if symptoms of pain or raised temperature …
Responded
Michael Harman
Concerns: Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.
Response (Centra Support1): Centra Support conducted a full internal review of working practices and welfare checks. They drew up and rolled out local guidance protocols for reporting incidents, following up with service users …
Responded
Amanda Hawkins
Concerns: Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.
Response (Dudley Walsall NHS Trust): The Trust will ensure outpatient letters from CRS North medical teams are copied to the care coordinator. A working group led by the Head of Recovery Services is looking at …
Overdue
Eve Cullen
Concerns: Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.
Response (Worcestershire Health Care NHS Trust): Worcestershire Health Care NHS Trust conducted a serious review and acknowledges differences in urgent referral processes across the county. As a result, it is working with North CCGs to introduce …
Responded
Pauline Taylor
Concerns: Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.
Response (Department of Health): The Department of Health acknowledges the concerns, notes BAUS's definition of nephroureterectomy, and states that decisions on clinical team operations are for the local Trust to address, also suggesting the …
Response (Leeds Teaching Hospital): The hospital clarified that "nephroureterectomy" means removal of the kidney with the whole ureter, emphasized this guidance to staff and included it in induction information. They filled Clinical Nurse Specialist …
Responded
Christopher Watson
Concerns: Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct contact to assess their capacity or needs.
Response (Norfolk County Council): Norfolk County Council has stopped sending letters to individuals about whom concerns have been raised, and staff have been instructed to make face-to-face contact when telephone contact is not possible. …
Responded
Maurice Camfield
Concerns: Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
Overdue
Robert Watt
Concerns: Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.
Overdue
Mary Hanson
Concerns: There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information on capacity and best interest assessment forms, and a staff nurse may not have been the appropriate person to complete the proforma.
Overdue
Michael George
Concerns: Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill patients, and there was a lack of domiciliary visits from consultant physicians to mental health wards.
Response (South London and Maudsley NHS Trust): South London and Maudsley NHS Trust outlines planned improvements to policies, audits, and risk management related to physical health monitoring for patients on anti-psychotics, including actions related to diabetes screening …
Responded
Masoud Ghaderi
Concerns: Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Response (Avon and Wiltshire NHS Trust): The Trust Engagement and Observation Policy will be reviewed to ensure consistent recording of engagements. The Clinical Executive has commissioned an audit of reviewing risks across inpatient units and will …
Overdue
Doreen England
Concerns: The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate leadership and medical cover. RMN training also failed to cover pressure sores sufficiently.
Response: NHS England will oversee a specific action plan to address deficiencies in care, particularly regarding pressure sore risk assessment. The matter has been tabled for discussion in the Quality Surveillance …
Overdue
Stephen Richardson
Concerns: Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of aspiration.
Response (University Hopsitals of North Midlands NHS Trust): The ward will look to implement a nurse 'champion' for patients attending with learning disabilities in the future.
Responded
Committee Recommendations (122) — showing 50 strongest matches
#44 — Ensure women's health hubs meet specific demographic needs, accounting for religious and cultural considerations.
Recommendation: Integrated care boards must ensure that their hubs meet the specific demographic needs of their populations, particularly accounting for religious and cultural considerations.
Gov response: We agree that women’s health hubs must be tailored to the needs of local populations. For that reason, improving health outcomes and reducing health inequalities are key aims of women’s health hubs, as set out …
Not Addressed
#17 — Enforce informed consent and halt painful gynaecological procedures lacking adequate pain relief.
Recommendation: The NHS must do more to monitor and enforce protocols governing procedures such hysteroscopy, IUD fitting and cervical screening and ensure that they are underpinned by informed consent and are trauma-informed. A risk assessment that allows a patient to make …
Gov response: We agree with the importance of robust data collection that supports analysis to help identify where and what interventions are most appropriate. NHS England’s plan on reforming elective care for patients (linked in ‘Introduction’ above) …
Accepted
#16 — NHS fails patients during routine reproductive procedures, neglecting duty of care and pain management.
Recommendation: The NHS is failing many patients who undergo routine reproductive healthcare procedures such as hysteroscopy, IUD fitting and cervical screening. In too many cases, we find that a duty of care from gynaecologists and other medical practitioners is absent. Women …
Gov response: Cutting waiting lists, including for gynaecology, is an important part of our health mission to build an NHS fit for the future and a top priority for this government. NHS England’s plan on reforming elective …
Under Consideration
#56 — Address inappropriate assessment processes for disabled children’s parents and implement Law Commission proposals.
Recommendation: It is deeply concerning to hear that parents of disabled children are being treated with suspicion and undergoing inappropriate assessment processes when reaching out for help. The Department for Education must address this as an urgent priority and ensure that …
Gov response: As set out in the protocol between the Lord Chancellor and the Law Commission, a Department for Education Minister will provide an interim response to the Commission as soon as possible and in any event …
Not Addressed
#12 — Ensure FGM survivors are informed of interpretation rights and receive trained, culturally sensitive interpreters.
Recommendation: FGM Specialist Clinics and Women’s Health Hubs should ensure that women are informed of their right to have an interpreter. Those interpreters must be appropriately trained and sensitive to the cultural sensitivities around FGM. (Recommendation, Paragraph 37) Reconstructive surgery
Gov response: Integrated Care Boards (ICBs) and NHS Providers are responsible for ensuring translation and interpretation services are available for all patients accessing primary care. As part of NHS England’s Improvement framework: community language translation and interpreting …
Partially Accepted
#11 — FGM survivors are often unaware of interpretation rights and face unsuitable interpreter services.
Recommendation: FGM survivors are not consistently being made aware that they are entitled to interpretation services. However, interpretation services that are available can be unsuitable and interpreters can lack the necessary 42 proficiency to advocate on behalf of survivors. This can …
Gov response: Integrated Care Boards (ICBs) and NHS Providers are responsible for ensuring translation and interpretation services are available for all patients accessing primary care. As part of NHS England’s Improvement framework: community language translation and interpreting …
Accepted
#1 — FGM survivors often lack awareness of long-term health complications and care needs
Recommendation: Survivors of female genital mutilation (FGM) experience profound physical, emotional and psychosexual consequences and require specialised care and support to manage these impacts. Despite this, survivors may not be aware that the health complications they experience are a consequence of …
Gov response: . Response: We agree this is an important area of research and are in the process of taking the recommendation forward. The National Institute for Health and Care Research (NIHR) is developing a call in …
Accepted
#64 — SEND families experience unsatisfactory interactions with local authority staff and EHC plans
Recommendation: Many children with SEND and their families continue to have unsatisfactory experiences when navigating the SEND system, particularly in their interactions with local authority staff. These challenges are often rooted in a failure to work empathetically in partnership with parents …
Gov response: We appreciate the Committee’s careful consideration of these issues and will respond to their recommendations on improving local authority accountability, including in relation to the SEND tribunal. Almost 95% of education, health and care plans …
Not Addressed
#17 — Ensure active parental involvement in all SEND processes with independent advocacy and resources
Recommendation: Parents and carers must be actively and meaningfully involved in all processes that affect their child’s education, support, and overall wellbeing. This includes being fully informed and invited to participate in all relevant meetings where decisions about their child’s needs …
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
#16 — Meaningful parental involvement is crucial for successful SEND system outcomes and trust
Recommendation: Parents and carers of children and young people with SEND often feel excluded from the processes that affect their children’s education and support. However, meaningful and collaborative parental involvement is essential to the success of the SEND system. When parents …
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
#47 — Require Government to detail actions addressing complex health needs of women in custody
Recommendation: The Government should respond to this report setting out what action it is taking to address the complex health and wellbeing needs of the women it currently has in its custody. (Recommendation, Paragraph 212) 88
Gov response: Accept. This Government recognises that there are too many women in prison, many of whom have multiple complex needs. Through the Womens Justice Board, we have set out a clear ambition to reduce the number …
Accepted
#46 — System failing to meet complex health and wellbeing needs of women in prison
Recommendation: Women in prison often have acute and complex health needs, yet the system is failing to meet even their most basic requirements. We acknowledge the Government’s ambition to reduce the population in the female prison estate, and that change is …
Gov response: Accept. This Government recognises that there are too many women in prison, many of whom have multiple complex needs. Through the Womens Justice Board, we have set out a clear ambition to reduce the number …
Accepted
#40 — Young Offender Institutions routinely fail to meet minimum education hours for children
Recommendation: Article 28 of the United Nations Convention on the Rights of the Child affirms that all children have the right to education, including those in detention. Yet Young Offender Institutions are routinely failing to meet the statutory minimum of 15 …
Gov response: Accept. The YCS recognises these failings and is addressing them through the Roadmaps to Effective Practice in Education outlined in paragraph 76-77. Many children and young people in custody have a disrupted education before coming …
Accepted
#37 — Publish updated Neurodiversity Action Plan detailing identification and support for prisoners
Recommendation: The Government must publish an update to the Neurodiversity Action Plan without further delay. It should include how they plan to systematically identify how many prisoners have neurodivergent needs, as well as how it aims to support them. (Recommendation, Paragraph …
Gov response: Accept. In response to the Joint Inspectorates’ Independent Review of neurodiversity in the criminal justice system, we have committed to publishing a final update to the Cross-Government Neurodiversity Action Plan imminently, setting out progress made …
Accepted
#36 — Lack of consistent data hinders support for neurodivergent prisoners in the system
Recommendation: It is unclear how the Government plans to support those with neurodivergent needs in the criminal justice system without having consistent and reliable data on how many neurodivergent prisoners there are. Furthermore, it is disappointing that those with neurodivergent needs, …
Gov response: Accept. In response to the Joint Inspectorates’ Independent Review of neurodiversity in the criminal justice system, we have committed to publishing a final update to the Cross-Government Neurodiversity Action Plan imminently, setting out progress made …
Accepted
#30 — Require Government to develop action plan for improving youth estate conditions, increasing time out of cell
Recommendation: The Government must respond to this report with an action plan as to how it plans to manage current conditions across the youth estate. For Young Offender Institutions, this should include what impact the introduction of 85 PAVA has had …
Gov response: Accept. We recognise that change was required to make improvements in the public sector YOIs and have developed a comprehensive plan to address the concerns raised by the inspectorate over the last decade. Site-specific action …
Accepted
#29 — Youth Custody Service and Young Offender Institutions fail children with excessive cell time
Recommendation: The Youth Custody Service, and in particular Young Offender Institutions, is clearly not working for children. Children should not be spending up to 23 hours a day in cell due to the failure of HMPPS to manage behaviour effectively. It …
Gov response: Accept. We recognise that change was required to make improvements in the public sector YOIs and have developed a comprehensive plan to address the concerns raised by the inspectorate over the last decade. Site-specific action …
Accepted
#26 — Require Government to produce plan for all prisoners to access full regime within three years
Recommendation: The Ministry of Justice must consider the benefits of giving remand prisoners access to all parts of the regime, should they choose to participate. In the event that this is not currently viable due to the prioritisation of courses for …
Gov response: 127. This Government recognises that there are too many women in prison, many of whom have multiple complex needs. Through the Womens Justice Board, we have set out a clear ambition to reduce the number …
Accepted
#23 — Lack of rehabilitative support for remand prisoners increases reoffending risk
Recommendation: Many remand prisoners are convicted but released straight from court without any rehabilitative support. This means they are more likely to reoffend. We welcome impending change as part of the Sentencing Bill; however, we are concerned this will not go …
Gov response: 108. The YCS recognises these failings and is addressing them through the Roadmaps to Effective Practice in Education outlined in paragraph 76-77. 109. Many children and young people in custody have a disrupted education before …
Accepted
#24 — Prioritise alliance models embedding VCFSE organisations in community mental health service design and delivery.
Recommendation: NHS England and Integrated Care Boards should prioritise the development of alliance models that embed voluntary, community, faith and social enterprise (VCFSE) organisations in the design and delivery of community mental health services. This should include clear expectations for co- …
No Published Response
#19 — Reinstate annual physical health check target for SMI and embed health outcomes in Modern Service Framework.
Recommendation: NHS England should reinstate the annual physical health check target for people with severe mental illness (SMI) in operational planning guidance. This target has driven significant progress and remains essential for accountability, monitoring co-morbidities, and reducing preventable deaths. Building on …
No Published Response
#16 — Publish clear guidance on key worker roles to ensure care coordination for service users.
Recommendation: In some areas, the emphasis on care coordination may have been lost through the rollout of the CMHF. We recommend that NHS England publish clear guidance on the role of key workers to ensure all service users have access to …
No Published Response
#14 — Detail lived experience involvement and integration of MSF with wider support systems.
Recommendation: We would also like the Government to set out how people with lived experience will be involved in its development and how the MSF will be integrated with wider systems of support including those provided by the VCFSE sector and …
No Published Response
#6 — Co-design new mental health care models with experts by experience
Recommendation: Our conclusions in this Chapter try to reflect what service users told us they wanted. This must be reflected in service design. As new models of care are commissioned and implemented, these must be co-designed with experts by experience to …
No Published Response
#5 — Co-production and peer support essential for trusted and effective mental health services
Recommendation: Services shaped and delivered with, and by, people with lived experience of mental illness are more trusted, accessible, and effective. Meaningful co-production—where power is shared and lived experience is valued—is essential to high-quality care. Peer support, in particular, is a …
No Published Response
#4 — Stigma and discrimination undermine equitable and culturally appropriate mental health services
Recommendation: Experiences of stigma, discrimination, and lack of culturally appropriate or personalised support were frequently reported, particularly by racialised communities, neurodivergent individuals, and those with disabilities. 74 Where care was described as high-quality, it was inclusive, responsive, and tailored to individual …
No Published Response
#3 — Current mental health services fail to provide person-centred, holistic care
Recommendation: Service users, their families, carers and loved ones have been clear: high- quality care must be person-centred, responsive to the full range of needs individuals experience, and ensure involvement of their wider networks. Current services too often fall short—focusing narrowly …
No Published Response
#2 — Lack of continuity of care fragments support for people with severe mental illness
Recommendation: Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, …
No Published Response
#30 —
Recommendation: We recommend that NHS England and Improvement establish a working group comprising of women and their families, organisations providing support for women throughout their pregnancy and clinicians to develop a set of actions for maternity services to consider in order …
Gov response: 125. We accept this recommendation in part. 126. NHSEI acknowledge concerns about a focus on “normality at any costs”. Our vision is that our staff of all professions and disciplines will work together with women …
Not Addressed
#9 — FGM survivors experience shame in healthcare due to inadequate cultural sensitivity training.
Recommendation: Evidence suggests some FGM survivors are experiencing shame or humiliation in healthcare settings, reducing the likelihood of them engaging further with healthcare services essential to their physical and mental wellbeing. Training for midwives and healthcare professionals is not mandatory and …
Gov response: Response: It is vital that all professionals with statutory safeguarding responsibilities such as the police, teachers and healthcare professionals have the right training and framework to identify victims and perpetrators of FGM and manage them …
Accepted
#65 — Improve local authority staff training on SEND law and parent engagement for better relationships
Recommendation: Local authority staff require improved training on child development, SEND law, parent engagement and mediation, alongside changes in practice that strengthen accountability and foster more constructive relationships with parents and carers. This should include meaningful parental involvement at every stage …
Gov response: We appreciate the Committee’s careful consideration of these issues and will respond to their recommendations on improving local authority accountability, including in relation to the SEND tribunal. Almost 95% of education, health and care plans …
Not Addressed
#23 — Engage parents of SEND children during area inspections on local inclusive practices
Recommendation: Area SEND inspections should engage with parents across the locality to gather the perspective of parents of children with SEND on the admissions policies and inclusive practices of local authorities, schools and multi- academy trusts in the area. (Recommendation, Paragraph …
Gov response: A new SEND inspection framework launched in January 2023, with all local areas to be inspected by 2027 to improve outcomes for children and young people with SEND. This inspection covers the role of the …
Accepted
#39 — Remove the six-year funding requirement to enable all prisoners to access higher education
Recommendation: Access to higher education should be based on rehabilitative potential, not sentence length. We repeat the recommendation of the previous Education Select Committee and encourage the Government to remove the six-year funding requirement to enable all prisoners to access higher …
Gov response: Partially Accept. The MoJ is committed to enabling prisoners to access higher education while in custody. We already work with partners such as the Prisoners Education Trust and the Open University to widen access for …
Not Addressed
#38 — Six-year funding rule hinders prisoner access to higher education despite proven benefits
Recommendation: Evidence shows that prisoners who participate in higher education are 20 per cent less likely to reoffend and commit 30 per cent fewer reoffences in the year following release. Reforming the six-year funding rule would support long-term prisoners to develop …
Gov response: Partially Accept. The MoJ is committed to enabling prisoners to access higher education while in custody. We already work with partners such as the Prisoners Education Trust and the Open University to widen access for …
Not Addressed
#35 — Publish clear plan with funding to improve prison education participation and quality
Recommendation: The Government must publish a clear plan, with an associated funding allocation, to improve both participation and quality in prison education. This should include steps to address poor Ofsted outcomes, ensure that all prisoners—including those on remand—have access to meaningful …
Gov response: Partially Accept. Education is central to rehabilitation and reducing reoffending, and we are taking steps to strengthen provision across the estate. Future funding will depend on allocations decisions, and we will provide an update to …
Partially Accepted
#32 — Significant real-term cuts to prison education budgets undermine reoffending reduction efforts
Recommendation: We are alarmed by reports of significant real-term cuts to prison education budgets, with some prisons facing reductions of up to 50 per cent. As this report makes clear, prison education is already underfunded when compared to provision in the …
Gov response: Partially Accept. The national prison education budget has not been cut. However, the cost of delivering high-quality education has increased significantly in recent years. Although the budget has slightly increased in cash terms, it has …
Partially Accepted
#21 — Release on Temporary Licence remains underutilised despite its proven effectiveness.
Recommendation: Release on temporary licence (ROTL) is a proven and effective tool for rehabilitation, helping prisoners maintain family ties, gain employment, and reintegrate into the community. Despite its strong track record, with a 99.8 per cent compliance rate, it remains inconsistently …
Gov response: 99. In response to the Joint Inspectorates’ Independent Review of neurodiversity in the criminal justice system, we have committed to publishing a final update to the Cross-Government Neurodiversity Action Plan imminently, setting out progress made …
Accepted
#16 — Statutory minimum time out of cell remains consistently unmet in prisons.
Recommendation: It is unacceptable that the statutory minimum for time out of cell is not being met, which means that prisoners either do not have access to basic needs, such as a shower or time in fresh air, or must choose …
Gov response: 72. The Government was elected with a landmark mission to halve violence against women and girls (VAWG) in a decade. We have published our VAWG Strategy which sets out our plan to do just that, …
Partially Accepted
#2 — Include measures to ensure rehabilitation is not compromised in the next prison capacity statement
Recommendation: In the next annual statement on prison capacity, the Government should set out not only how it intends to manage the demand and supply of prison places, but also the steps it will take to ensure that rehabilitation is not …
Gov response: 4. HMPPS is dedicated to making sure staff have the necessary knowledge and skills to perform their jobs effectively and partially accepts this recommendation. Though there will be instances where staff are temporarily promoted to …
Partially Accepted
#28 —
Recommendation: The Expert Panel overall rated the Government’s progress towards providing personalised care as ‘Inadequate’. We believe that personalisation must go hand in hand with safety and women must be fully and impartially informed about the safety risks associated with all …
Gov response: 125. We accept this recommendation in part. 126. NHSEI acknowledge concerns about a focus on “normality at any costs”. Our vision is that our staff of all professions and disciplines will work together with women …
Not Addressed
#12 —
Recommendation: We recommend that, in addition to the implementation of the Mental Health Units (Use of Force Act) (i.e. ‘Seni’s Law’), all Assessment and Treatment Units (ATUs) are closed within two years and replaced with person-centred services that are: i) designed …
Gov response: We agree with some of this suggestion. It is important that we have places that people can go for mental health treatment if they need it. Where people have to go to a mental health …
Under Consideration
#6 —
Recommendation: As emphasised by Alzheimer’s Society and other key stakeholders, social care reform must be “rooted in the recognition of what good quality care looks like” and 20 Supporting people with dementia and their carers create a system where people with …
No Published Response
#2 —
Recommendation: It is not appropriate to set a numerical target for the proportion of appointments carried out remotely in general practice. Instead practices should respond to the needs of their local populations and work together with patients to establish the most …
Gov response: Accept. It is not appropriate to set a numerical target for the proportion of appointments carried out remotely in general practice. Instead, practices should respond to the needs of their local populations and work together …
Under Consideration
#13 — Reestablish national board led by autistic and learning disabled people to improve health outcomes.
Recommendation: The Government should reestablish a national board with a focus on improving health inequalities for people with a learning disability and autistic people across all health and social care services. That board should include, and be led by, people with …
Response Pending
#12 — Voices of autistic people and those with learning disabilities are often missing in health decision-making.
Recommendation: People with a learning disability and autistic people, and the people who care for them, are the real experts when it comes to their health and care needs. However, aside from the occasional opportunity to feed into consultations, their voices …
Response Pending
#23 — Benign gynaecology' terminology downplays reproductive health conditions, risking treatment de-prioritisation
Recommendation: The use of terminology such as ‘benign gynaecology’ downplays the impact of reproductive health conditions and risks de-prioritising them for treatment that could significantly improve patients’ health and lives.
Gov response: Primary care is often the first point of contact for women seeking help with their reproductive health and so it’s vital that GPs are well supported to care for reproductive health conditions. Doctors must regularly …
Under Consideration
#7 — Enhance NHS website and app to be comprehensive, accessible, inclusive, and highly-visible
Recommendation: We know that many women and girls are using online spaces to get information and seek help while there are gaps in support in medical fields. It is therefore imperative that the NHS and trusted sources become a first-port-of-call to …
Gov response: As referenced in the report, RCOG is developing a guideline on the care of trans and gender-diverse adults in obstetrics and gynaecology. RCOG aims to publish this in 2026. The government is committed to delivering …
Under Consideration
#6 — Ongoing NHS website improvements for women's reproductive health information are welcomed
Recommendation: We welcome the ongoing improvements to the NHS website to include information about a wider range of women’s reproductive health conditions, information to specific communities and signposts to support and the ambition to include that information in alternative formats.
Gov response: Cutting waiting lists, including for gynaecology, is a critical part of our health mission to build an NHS fit for the future and a top priority for this government. NHS England’s plan on reforming elective …
Accepted
#7 — Many FGM survivors lack access to appropriate specialist counselling services
Recommendation: FGM survivors often suffer psychosexual, emotional and mental health complications from undergoing FGM. However, many FGM survivors do not have access to appropriate counselling services, with many FGM services not offering any counselling to FGM survivors and others offering counselling …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Partially Accepted
#44 — Further education provision for post-16 SEND learners lacks adequate policy focus and funding.
Recommendation: Greater policy focus is required on further education provision for young people with SEND. At present, both FE and SEND policy frameworks give limited consideration to the specific needs of learners post-16, and funding arrangements often fail to provide adequate …
Gov response: The Government’s ambition is that all young people with SEND receive the right support to succeed in post-16 education and as they move into adult life. Post-16 education offers a range of pathways covering academic …
Accepted
CQC Inspection Actions (349) — showing 50 strongest matches
Chy Byghan Residential Home
The provider must ensure people are provided with person-centred care that meets their needs and reflects their preferences.
Must Do
Assured Care Formby
Care plans did not detail people's likes. dislikes and preferences. People had not always been involved in planning their care.
Must Do
Woodland Care Home
The registered provider had not provided person-centred, goal-orientated care that reflected the preferences of people who used the service.
Must Do
Winterton House
Care did not always meet need or reflect people's preferences. Care or treatment was not always designed with a view to achieving service users' preferences and ensuring their needs were met.
Must Do
Verve Health
The service must involve service users in care planning and risk assessment.
Must Do
Southwinds
The provider did not ensure that people received person centred care that met their needs and reflected their preferences.
Must Do
Reside at Southwood
Proper steps had not been taken to ensure that people receive appropriate person-centred care and treatment that is based on an assessment of their needs and preferences.
Must Do
Nower House
The failure to ensure people's rights were upheld in line with the MCA was a continued breach of regulation 11 (Need for consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Nower House
The failure to ensure person-centred care was a continued breach of regulation 9 (Need for consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Havilah Office
The provider did not carry out collaboratively with the person an assessment of their needs and preferences for their care or design care with a view to achieving service user's preferences and ensuring their needs were met. Regulation 9(3)(a)(b)
Must Do
Benthorn Lodge
The registered person failed to ensure that the care and treatment provided to people was appropriate and met their needs and preferences. In addition the registered persons person had not made suitable arrangements to ensure that people were enabled to …
Must Do
Benedict House Nursing Home
The provider must ensure people using the service receive person-centred care that reflects their needs or their personal preferences.
Must Do
The Peter Gidney Neurodisability Centre
People's likes and dislikes were not taken into account.
Must Do
The Peter Gidney Neurodisability Centre
People were not involved in the drawing up of their own care plans.
Must Do
The Old Rectory
The provider was not acting in accordance with the Mental Capacity Act 2005. Where people were people were unable to consent, mental capacity assessments had not been completed and best interests decisions had not been evidenced. Regulation 11 (1).
Must Do
The Old Rectory
The provider did not ensure that people who used the service received individualised care that reflected their personal preferences. Regulation 9 (1).
Must Do
St. David's Home
The provider had failed to ensure that service users' care and treatment was managed in a way that ensured it was always appropriate, met their needs or reflected their preferences.
Must Do
Spindrift Care Home Limited
The provider was not working within the principles of the Mental Capacity Act 2005. The provider had not undertaken any assessment of people's capacity to make decisions. Decisions had been made on people's behalf without ensuring they were in the …
Must Do
Prospects for People with Learning Disabilities - 3 Norwich Road
People's care plans were not always written in a person centred way. In one care plan the person's name was incorrect on a number of occasions in their care plan. Some of the information in people's care records was duplicated …
Should Do
Newland House
People were not receiving care which was person-centred or reflected personal preferences.
Must Do
New Dawn Healthcare - Unit 18 Blackheath Business Centre
The registered person did not always ensure that care was delivered to people with a view to achieving their preferences and ensuring their needs were met.
Must Do
Moorview Care (Derby)
The provider did not ensure people received person centred care which met their needs and preferences.
Must Do
Ivydene Care Home
People's consent to their care and treatment was not always considered in line with the Mental Capacity Act 2005. Regulation 13 (1).
Must Do
Homesaints Limited
The provider must ensure people's preferences are fully explored, care is person-centred, concerns are responded to with a view to improving care, and people's care needs in relation to meals, care visit times and choice of staff are upheld.
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure valid consent is obtained and recorded, and best interests decisions are made and documented where capacity is lacking.
Must Do
Forge House Services Limited
Care plan reviews required further improvement to identify areas which needed to be reworded to be more respectful.
Should Do
Forge House Services Limited
The registered manager should review and rewrite care plans where comments were not always respectful, to ensure respectful terminology.
Should Do
Copper Beeches Lodge
The provider must comply with Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Bio Luminuex Health Care
The provider must ensure person-centred care.
Must Do
Ashington Gardens
Regulation 9 HSCA RA Regulations 2014 Person-centred care
Must Do
Woodlands
The provider failed to ensure they had done everything reasonably practicable to make sure people who used the service received person-centred care and support that was appropriate, met their needs and reflected their personal preferences.
Must Do
Woodland Care Home
The care and treatment of service users must (a) be appropriate, (b) meet their needs, and (c) reflect their preferences.
Must Do
Winterton House
Care did not always meet need or reflect people's preferences. Care or treatment was not always designed with a view to achieving service users' preferences and ensuring their needs were met.
Must Do
Vision Rolleston
Regulation 11 HSCA RA Regulations 2014 Need for consent
Must Do
Victoriana Care Home
The provider must ensure people receive person-centred care tailored to their preferences, likes and dislikes and are supported to take part in social past times relevant to them.
Must Do
The Croft
Regulation 9 (Person-centred care)
Must Do
The Cottage Residential Home
The provider must ensure people receive person-centred care which has been agreed and meets their assessed needs.
Must Do
TOB Care services Ltd
People's capacity to make decisions about their care and support were not assessed on an on-going basis in line with the Mental Capacity Act (MCA) (2005).
Must Do
TOB Care services Ltd
People's needs and choices were not delivered in line with standards, guidance and the law. People were not supported to access appropriate healthcare services. People did not receive person-centred care and support.
Must Do
St.Theresa's Nursing Home
The provider must ensure that the care and treatment of service users is appropriate and meets their needs, including ensuring the range of activities available to people is meaningful and arranged to meet individual needs, especially for those with memory …
Must Do
Reside at Southwood
proper steps had not been taken to ensure that people received the care, treatment and support they required to meet their needs.
Must Do
Oaklands Care Home
The provider must ensure people receive personalised care that is responsive to their needs.
Must Do
Nower House
The failure to ensure people's rights were upheld in line with the MCA was a continued breach of regulation 11.
Must Do
Nower House
The failure to ensure person-centred care was a continued breach of regulation 9
Must Do
Melville House
The provider must ensure that people's individual needs are fully understood and met through person-centred care.
Must Do
Kingsley Nursing Home
The registered manager and provider failed to involve people in their care planning or provide care that reflected their preferences or met their needs. 9 (1a and b) (3)
Must Do
Floron Residential Home for the Elderly
The provider was not making sure people who use the service received person-centred care to meet their needs and reflected their personal preferences. This was a breach of Regulation 9 (Person-Centred Care) of the Health and Social Care Act 2008 …
Must Do
Fairglen Residential Home
The provider must ensure people receive care and support in line with their needs and preferences.
Must Do
Fairglen Residential Home
The provider must ensure people are supported in line with the principles of the Mental Capacity Act 2005 (MCA).
Must Do
Etherley Lodge
The provider must ensure that care is person-centred, that staff have sufficient information to respond to people’s changing health needs, and that people’s individual needs and preferences are incorporated into their care plans and acted upon.
Must Do
ICIBI Immigration Recommendations (2)
An inspection of asylum casework (August 2020 – May 2021)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
An inspection of asylum casework (June - October 2023)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
PPO Death in Custody Recommendations (48)
The Governor
The Governor should ensure that the key worker scheme provides meaningful and ongoing support to all prisoners in line with national policy.
The Head of Healthcare
The Head of Healthcare should develop a food and fluid refusal policy to ensure that staff understand how they should manage prisoners who refuse food and fluids and that: a food and fluid refusal care plan is initiated promptly and …
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that CVOP meetings are clinically multidisciplinary, that effective care plans are created and implemented, and that the meetings are accurately minuted.
The Director of HMP Lowdham Grange
The Director might wish to consider how key-workers structure meetings with prisoners to focus on specific areas of concern.
The Governor of HMP The Mount
The Governor should ensure that the key worker scheme provides meaningful and ongoing support to all prisoners in line with national policy.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that applications for early release on compassionate grounds for prisoners with terminal illnesses are prioritised, and that a record is kept of action taken.
The Governor
there are regular wellbeing checks on prisoners subject to possible extradition or deportation to assess whether their risk to themselves has changed.
The Governor
staff understand the importance of having regular, meaningful conversations with prisoners to identify changes in appearance, behaviour or mood that may indicate increased risk;
The Governor
all prisoners receive regular wellbeing checks during the restricted pandemic regime, in line with the Exceptional Delivery Model and that these are recorded on NOMIS;
The Governor
The Governor should ensure that staff understand the importance of having meaningful conversations with prisoners where possible when carrying out welfare checks during the restricted regime.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are involved in their end-of-life care where practicably possible and that patient involvement in these discussions is recorded in the clinical notes.
The Head of Healthcare
The Head of Healthcare should set out a clear pain management pathway for prisoners and ensure staff follow it.
The Head of Healthcare
The Head of Healthcare should ensure that effective arrangements are in place to escalate concerns about patients at risk who do not cooperate with healthcare interventions and to respond appropriately following reports of overdose.
The Head of Healthcare at HMP Frankland
The Head of Healthcare should ensure that a medication review is undertaken when a patient does not request a repeat prescription of critical medications. This will ensure that the patients reasoning for non-concordance can be discussed and documented.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who present with persistent and challenging behaviours are assessed according to their level of risk and need, with consideration given to their most suitable location.
The Head of Healthcare
The Head of Healthcare should ensure that there are systems and processes in place to support ongoing clinical management of prisoners with challenging behaviour, which should include assessing mental capacity.
The Head of Healthcare
The Head of Healthcare should ensure that a prisoner’s perspective on detoxification is sought and recorded.
The Head of Healthcare and the Regional Manager for PPG
The Head of Healthcare and the Regional Manager for PPG should be assured that there is a refusal of care pathway in place which supports practitioners caring for patients who refuse treatment to a point of their self-neglect.
The Governor and Head of Healthcare
they should have been aware that Mr Malt had a DNACPR in place and respected his wishes.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff fully and clearly document conversations and decisions about patients who refuse medical treatment, including consideration of their mental capacity.
The Governor
The Governor should ensure that after a prisoner dies, prisoners who were close to him are informed of the death personally and offered appropriate, individual support.
The Head of Healthcare
The Head of Healthcare should review the process for managing and monitoring long-term conditions to ensure the development of meaningful patient-centred care plans.
The Governor
The Governor should ensure that staff are reminded not to use inappropriate or insensitive language towards prisoners, particularly, those being monitored under ACCT procedures.
The Governor of HMP Send
It would have been appropriate for prison staff to consider ROTL for Ms Chapman at the same time that they submitted her application for early release on compassionate grounds.
The Governor and Head of Healthcare
ensure that staff use appropriate interpretation services when discussing complex matters with prisoners with limited English language skills.
The Head of Healthcare
The Head of Healthcare should ensure that staff see prisoners at the agreed frequency, in line with their care or support plan.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prisoners who are not taking or collecting their medication are identified and reviewed, and that prisoners choosing to isolate are able to safely collect and take their medication.
The Governor
The Governor should ensure that the ongoing review of the local Self-Isolation Strategy includes that isolating prisoners are properly supported, and that staff are trained in supporting prisoners towards ending self-isolation.
The Governor
The Governor should ensure that the review of the prison debt strategy considers care planning for known debtors and ensures that all agreed care plans are recorded on the prisoner’s record and therefore available for all staff to see.
The Governor and Head of Healthcare
healthcare staff review and document the mental state of a self-isolating prisoner at least once a week.
The Governor and Head of Healthcare
prison staff regularly review plans and ensure that any changes are recorded and actioned; and
The Governor and Head of Healthcare
plans for isolating prisoners contain detailed information about identified risks and agreed actions to reduce or end isolation,
The Director and Head of Healthcare at Parc
The Director and Head of Healthcare at Parc should liaise with the Medical Director for G4S and arrange an urgent meeting with the Chief Executive of Abertawe Bro Morgannwg University Health Board to ensure that full service provision for patients …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a robust process in place to ensure that applications for early compassionate release are properly monitored and completed without delay.
The Head of Healthcare
The Head of Healthcare should ensure that a formal mental capacity assessment is promptly completed and fully documented when there are concerns that a prisoner has declined medical advice or treatment.
The Head of Healthcare
The Head of Healthcare should review the current documentation process for DNACPR decisions and consider adopting the ReSPECT form.
The Head of Healthcare
The Head of Healthcare should remind staff to ensure that patients understand the risks of refusing medical tests and clearly document this in medical records.
The Director and Head of Healthcare of HMP Peterborough
The Director and Head of Healthcare should ensure that staff use approved interpretation services to communicate with non-English speaking prisoners when discussing confidential or complex matters.
The Head of Healthcare
The Head of Healthcare should ensure that if a patient refuses investigation of potential medical conditions, healthcare staff fully explore and document the reasons, and consider whether they need information or support to address any concerns.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should explore alternative options for meeting a prisoner’s care needs when they cannot be met on a standard wing.
The Head of Healthcare
The Head of Healthcare should ensure that personalised care plans with aims, planned interventions and monitoring, are in place for all patients with long-term health conditions.
The Governor of HMP Gartree
The Governor should ensure that staff understand the requirements for Release on Temporary Licence for medical purposes and a robust process is implemented to ensure applications are made when appropriate.
The Governor of HMP Gartree
The Governor should ensure that a robust process is in place to review Early Release on Compassionate Grounds (ERCG) refusals and resubmit applications where an individual’s health has deteriorated.
The Head of Healthcare
The Head of Healthcare should ensure that patients with multiple healthcare needs are discussed at the multi professional complex case conference meeting so that the MDT has full oversight of their complex care and multiple care needs.
The Head of Healthcare
The Head of Healthcare should ensure that the appropriate persons are being discussed in the multi professional complex case conference (MPCCC) so that the wider healthcare team have full oversight of their needs.
The Head of Healthcare
The Head of Healthcare to ensure that all patients who have life limiting conditions have an advanced care plan in place in accordance with the National Institute for Health and Care Excellence (NICE) guideline [NG142] for ‘end of life care …
The Governor of HMP Risley
bedwatch staff understand the need to treat prisoners’ visitors sensitively;
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who decline COVID-19 vaccinations are given the opportunity to reconsider their decision, and that healthcare staff discuss and record the reasons for the refusal.
PHSO Ombudsman Recommendations (2)
Discharge from mental health care: making it safe and patient-centred
NHS England should make sure that patients and their support network are active and valued partners in planning transitions of care and are empowered to give feedback, including through complaints.
Discharge from mental health care: making it safe and patient-centred
NHS England and Integrated Care Boards should make sure that people who are being discharged from mental health settings can choose a nominated person to be involved in discussions and decision-making around transitions of care.
IMB Annual Reports (35)
The Verne (2021)
HMP The Verne experienced a challenging year due to the COVID-19 pandemic, which caused a major outbreak, significant staff absences, and disruption to the prison regime, including education, work, and visits. Despite these challenges, the prison maintained a very safe environment with low violence, and the Board commended staff dedication and the strong ethos of mutual respect. Key concerns persist regarding the provision of 24-hour social and healthcare for the ageing population, slow progress on a proposed hospital unit, and the need for more purposeful activity.
PRISON
Key concerns
Stafford (2021)
This IMB annual report for HMP Stafford, a Category C training prison, covers a period significantly impacted by the Covid-19 pandemic. Key concerns include persistent poor medicines management, deteriorating staff-resident relationships, and the challenges of a highly restrictive regime compounded by a lack of in-cell telephony. Positive aspects noted were low violence and drug levels, successful vaccine rollout, and comprehensive in-cell activity provision.
PRISON
Key concerns
Coldingley (2021)
HMP Coldingley, a Category C training prison, faced significant challenges due to the Covid-19 pandemic, impacting regime, education, and work. The Board commends staff for maintaining a humane regime, containing Covid-19 outbreaks, and facilitating out-of-cell time. Key concerns include illicit items leading to violence, the lack of in-cell sanitation in older wings, and the poor state of the estate. The report highlights progress in areas like new accommodation pods and education initiatives but calls for addressing long-standing issues such as IPP prisoners and resettlement challenges.
PRISON
Key concerns
Dover Short Term Holding Facilities (2021)
The Dover Independent Monitoring Board raises urgent concerns about the continuing and worsening conditions at Tug Haven, Kent Intake Unit (KIU), and Frontier House. Facilities are severely overcrowded, leading to migrants, including vulnerable children, sleeping in unheated and unsanitary tents. Significant issues with undetected injuries, inadequate medical screening, and insufficient healthcare staffing are highlighted, along with staff demoralisation and safety incidents stemming from the challenging environment.
PRISON
Key concerns
Wayland (2023)
This report on HMP Wayland, based on a prisoner attitudes survey ending March 2023, highlights significant concerns across various aspects of prison life. Key issues include ineffective induction, poor staff-prisoner trust and communication, and a failure of the key worker scheme. Prisoners report feeling unsafe, lacking support for resettlement, and facing challenges with property, healthcare access, and the complaints system, alongside issues in education provision. The Board emphasizes a general lack of curiosity from management regarding these persistent problems, underscoring the need for fundamental improvements.
PRISON
Key concerns
Usk and Prescoed (2024)
HMP Usk and Prescoed are considered well-managed with positive outcomes for prisoners, who generally report feeling safe. Key strengths include high levels of purposeful activity, positive staff-prisoner relationships, and good healthcare, despite staffing concerns. However, the Board highlights issues such as the lack of IPP prisoner recategorisation, parole board delays, inadequate healthcare and probation staffing, and persistent property loss during transfers.
PRISON
Key concerns
Send (2024)
HMP Send is a closed prison for adult women and transgender prisoners, reporting a population of 247 at the end of March 2024, with an operational capacity of 255. The Board generally found staff efforts commendable in ensuring safety, noting reductions in self-harm and assaults compared to the previous year. Key concerns highlighted include the persistent lack of in-cell technology, staffing shortages affecting offender management and mental health services, and the continued detention of IPP prisoners.
PRISON
Key concerns
Whatton (2024)
HMP Whatton, a Category C training prison for sex offenders, had an average population of 849 during the reporting year. The Board observed generally positive prisoner-staff relationships, improvements in healthcare staffing, and good access to purposeful activity with 758 workspaces. However, key concerns include the unsuitability of B wing accommodation, long waits for specialist courses, the disproportionate number of IPP prisoners, and challenges in securing employment for sex offenders post-release.
PRISON
Key concerns
The Verne (2024)
HMP The Verne is a Category C training prison for sex offenders, holding 605 prisoners with an operational capacity of 608. The IMB noted generally good staff-prisoner relationships and effective healthcare, but raised significant concerns about the deplorable state of the healthcare building and kitchen roof. Key issues also include the barely functioning key worker scheme, a backlog in OASys assessments, and increased bullying linked to the prison's more moderate regime.
PRISON
Key concerns
Wayland (2024)
The IMB's latest survey at HMP Wayland shows a generally positive shift across many areas, including improved induction experiences, property handling, and healthcare complaint responses. However, significant challenges persist, particularly concerning staff's ability to provide effective support for personal issues and loneliness, which has worsened. Concerns also remain regarding cell decency, the pervasive availability of drugs, inadequate resettlement preparation, and the perceived unfairness of the complaints system, indicating much work is still needed.
PRISON
Key concerns
Wayland (2025)
The Wayland IMB's 2025 prisoner attitudes survey reveals a concerning decline in prisoner safety and trust, alongside persistent issues with basic decency standards in accommodation. While some improvements were noted in literacy support and property reception, significant challenges remain in staff-prisoner relationships, access to healthcare appointments, and the overall restrictiveness of the regime. The report highlights high levels of loneliness and a substantial drop in family visits, urging management to address these core concerns to improve prisoner welfare and prepare them for release.
PRISON
Key concerns
Heathrow and City airports Short Term Holding Facilities (2021)
The reporting period was significantly impacted by the Covid-19 pandemic, leading to concerns about infection control, longer detainee stays, and increased waiting times. Key issues included slow implementation of effective Covid-19 measures, inability for detainees to access personal medication, and inadequate hygiene and family facilities in some terminals. Despite these challenges, Detention Custody Officers were observed to be largely kind and courteous.
PRISON
Key concerns
East Sutton Park (2021)
HMP East Sutton Park is an open prison for women, commended by the Board for being a safe and well-run establishment during a period affected by the Covid-19 pandemic. Key strengths include strong healthcare provision, effective resettlement preparation with good accommodation and employment outcomes, and valuable educational programmes. Challenges persist with ensuring prisoners are transferred with sufficient time to serve, effectively utilizing the IEP scheme for disruptive behaviour, and managing weekend medication administration.
PRISON
Key concerns
Grendon (2021)
HMP Grendon demonstrated a safe environment in 2021 with improvements across several safety indicators including self-harm, assaults, and ACCTs, despite ongoing Covid-19 restrictions and fire safety works. The Board commended improvements in diversity and inclusion, healthcare access, and vaccine rollout. However, significant concerns remain regarding the persistent issues with the night sanitation system, the loss of community ethos, and the impact of fire safety project delays on therapeutic capacity. The lack of in-cell telephony and data on cell bell response times also pose ongoing challenges.
PRISON
Key concerns
Charter Flight Monitoring Team (CFMT) (2021)
The IMB Charter Flight Monitoring Team (CFMT) report for 2021 found that while many returnees were treated with respect and efforts were made for infection control, significant concerns persisted regarding the fairness and humanity of the removal process. Key issues included prolonged in-vehicle confinement for returnees, inconsistent use of restraints, and communication gaps due to a lack of interpreters. The report also highlighted deficiencies in the provision of welfare items and information, especially for vulnerable individuals, and repeated recommendations on issues like distant airports and privacy on flights.
PRISON
Key concerns
London Heathrow and City Airports (2022)
This IMB report for Heathrow and City Airports' Short-Term Holding Facilities covers February 2021 to January 2022. It highlights ongoing concerns regarding extended detention times, inadequate facilities—especially for families in Terminal 5—and a critical lack of Wi-Fi and consistent access to medication across all sites. Despite these issues, the Board notes positive developments such as improved access to medical support at Heathrow, updated religious provisions, and generally respectful interactions from staff, while urging further improvements in staffing, infrastructure, and detainee welfare.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
This IMB annual report for Scotland and Northern Ireland's Short-Term Holding Facilities (STHFs) highlights significant welfare concerns for the reporting year ending January 2022. Key issues include widespread disability access shortfalls across the estate, an unacceptable increase in extended detentions in unsuitable airport holding rooms, and the unresolved problem of managing detainees' prescription medication. The Board also notes long-overdue facility upgrades at Larne House and inadequate ventilation systems, particularly concerning Covid-19 risks.
PRISON
Key concerns
Dungavel House IRC (2021)
Dungavel IRC was well-managed by both GEO and Mitie throughout 2021 despite COVID-19 challenges, treating residents fairly and safely. Healthcare provision was good, and a relaxed regime with ample activities was maintained due to low resident numbers. Key concerns included IMB member recruitment, high CSU temperatures, the need for a disability officer, and unresolved issues like staff negotiation training and parking.
IRC
Key concerns
Stafford (2024)
HMP Stafford, a Category C training prison for men convicted of sexual offenses, is largely perceived as safe and calm, with commendations for staff and positive developments in medicines management. However, the Board raised significant concerns over persistent legionella issues and inadequate shower facilities, ongoing staff shortages impacting regime, and the unaddressed plight of IPP prisoners. Challenges also include the poor state of healthcare facilities, insufficient neurodiversity support funding, and difficulties in Board member recruitment.
PRISON
Key concerns
Preston (2024)
HMP/YOI Preston is a Category B local prison for men, with an average population of 670 and an operational capacity of 680. The prison recorded four deaths in custody and opened 736 ACCT cases, reflecting high self-harm rates, while violence remained an issue. Positive developments include increased time out of cell and a fully operational key worker scheme. However, key concerns include the poor state of the Victorian estate, inadequate kitchen maintenance, and gaps in resettlement support from external agencies, especially for remand prisoners.
PRISON
Key concerns
Rye Hill (2024)
HMP Rye Hill is a privately run Category B training prison for men convicted of sexual offences, currently transitioning to become an all-Category C facility, holding 662 prisoners against an operational capacity of 625. The report highlights improvements in education and employment, good staff-prisoner relationships, and a new neurodiversity team, but raises significant concerns about the systemic injustice of IPP sentences, protracted compassionate release processes, and persistent issues with property transfers and inter-prison moves.
PRISON
Key concerns
Warren Hill (2024)
HMP Warren Hill is a Category C prison maintaining a safe and humane environment with effective safety measures and good staff-prisoner relationships. Key concerns include the outsourced food provision, the impact of Ministerial intervention on prisoner progression and ROTL, and the need for investment in the estate and digital education. The IMB highlights improvements in key worker delivery, healthcare, and resettlement support, advocating for on-site kitchen facilities and reinstatement of ROTL to further enhance prisoner experience and preparation for release.
PRISON
Key concerns
Stocken (2024)
HMP Stocken is a Category C training prison with an operational capacity of 1,071, generally providing a safe and humane environment. The report highlights improvements in education and vocational training and increased staff recruitment and retention, but raises concerns about prolonged mental health transfer delays, property transfer issues, and the prison's unfunded role in direct resettlement. The Board also notes the need for refurbishment in older parts of the estate and long waiting times for accredited programmes.
PRISON
Key concerns
Thameside (2024)
HMP Thameside is a privately operated local Category B/C prison for adult male prisoners, often occupied close to its operational capacity of 1232, with a 75% remand population. The IMB reports persistent concerns regarding healthcare provision, increasing delays in mental health transfers, and issues with the maintenance of the estate including lifts and in-cell technology. While some improvements have been noted in areas like reception, significant challenges remain in staffing, violence reduction, and ensuring fair and humane treatment, particularly concerning property management and the disproportionate disciplining of Black/mixed race prisoners.
PRISON
Key concerns
Peterborough (men) (2024)
HMP/YOI Peterborough (Men) is a category B remand, local and reception/resettlement prison run by Sodexo Justice Services, with an operational capacity of 944. The reporting year was challenging due to population pressures, staff shortages, and management changes, resulting in a restricted regime and impacted prisoner morale. Despite efforts to maintain safety, concerns persist regarding purposeful activity, healthcare provision, and the quality of key work.
PRISON
Key concerns
Peterborough (women) (2024)
HMP/YOI Peterborough (Women) struggled significantly with a lack of decent regime and severe staffing shortages during the reporting year, impacting prisoner morale and increasing violence. While management of self-harm and staff-prisoner relations remained commendable, issues with the new healthcare provider regarding medication, complaints, and mental health waiting lists persisted. The Board expressed strong concerns about the slow progress on mental health legislation and the critical need for improved purposeful activity and resettlement accommodation for women.
PRISON
Key concerns
Sudbury (2024)
HMP/YOI Sudbury, an open Category D resettlement prison, ended its reporting year with 507 prisoners. The report notes no deaths in custody and low self-harm incidents but highlights recurring concerns regarding the poor standard of dormitory accommodation and significant issues with prisoner property loss on transfer. While commendations are made for effective resettlement programs and improved complaint responses, the Board calls for improvements in digital connectivity, broader activity provision, and more consistent staff contact, particularly for new arrivals.
PRISON
Key concerns
Portland (2024)
HMP/YOI Portland continued to face significant challenges during the reporting year, primarily due to staff shortages and overcrowding, which impacted regime delivery and the reintroduction of double cells. Violence and self-harm incidents increased substantially, although measures to improve safety and reduce illicit substances showed some positive results. Healthcare staffing improved, but mental health provision and transfers remained a concern, while resettlement efforts were severely strained by poorly implemented early release schemes.
PRISON
Key concerns
Send (2025)
HMP Send, a closed prison for adult women, managed a population of 245 prisoners against an operational capacity of 255. The Board commended staff efforts in ensuring safety and positive relationships, noting improvements in complaint handling. However, the report highlighted significant increases in self-harm, assaults, and use of force incidents, along with persistent concerns regarding the adequacy of mental health provision for complex needs prisoners, the lack of digital technology access, and issues with inter-prison transfers.
PRISON
Key concerns
Erlestoke (2021)
HMP Erlestoke generally maintained a safe and humane environment during the reporting year ending March 2021, despite the challenges of Covid-19. Key improvements included a significant reduction in violence, commendable healthcare management of a Covid-19 outbreak, and improved resettlement planning. However, concerns remain regarding a troubling increase in self-harm, inadequate provision for prisoners with complex needs and IPP sentences, estates issues, and the impact of regime restrictions on purposeful activity.
PRISON
Key concerns
Cardiff (2021)
HMP Cardiff maintained a reasonably safe and humane environment during the reporting year despite significant Covid-19 challenges. Self-harm and use of force incidents reduced, and healthcare staffing improved, but a restrictive regime impacted prisoner wellbeing and purposeful activity. Key concerns include a lack of mental health transfer beds, inadequate accommodation on release, and ongoing issues with prison infrastructure and perceived discrimination against BAME prisoners.
PRISON
Key concerns
Moorland (2022)
HMP/YOI Moorland, a Category C resettlement prison, reported a population of 915 against a reduced operational capacity of 964 for the year ending February 2022. The report noted positive trends with reduced self-harm and violence incidents but highlighted significant concerns regarding the treatment and progression of IPP prisoners and persistent delays in mental health transfers. Staffing shortages affected key worker provision and programme delivery, while long waiting times for dental care were also an issue.
PRISON
Key concerns
Rye Hill (2022)
HMP Rye Hill adapted its regime throughout the year due to ongoing Covid-19 restrictions, maintaining a safe and secure environment with reductions in self-harm and violence. The Board commends the prison's communication strategy and staff efforts, but highlights significant concerns regarding IPP prisoner progression, end-of-life care procedures, and the lack of specialist resettlement support for sex offenders released directly from the prison. Healthcare provision faces challenges with a pending change of provider and long waiting times for care assessments.
PRISON
Key concerns
North Sea Camp (2022)
HMP North Sea Camp is an open Category D male resettlement prison. This report covers the period from March 2021 to February 2022, during which the prison managed a return to a more normal regime following Covid-19 restrictions, demonstrating strong rehabilitative efforts and good healthcare provision. Key concerns persist regarding end-of-life care, inadequate accommodation and accessibility for disabled prisoners, delays in offender management, and issues with contracted maintenance and property transfers.
PRISON
Key concerns
Lincoln (2022)
HMP/YOI Lincoln is regarded as a well-managed Category B local prison, successfully maintaining a humane regime and significantly reducing violence and self-harm despite operational challenges from its Victorian buildings and the pandemic. The Board noted positive developments in healthcare and staff-prisoner relations, alongside efforts to improve the estate. However, significant concerns persist regarding slow progress on repairs, the high incidence of homelessness among discharged prisoners, and the lack of specialist mental health services for personality disorders.
PRISON
Key concerns
IMB Recommendations (75) — showing 50 strongest matches
London STHF (2024)
In past reports we have recommended that DCOs should be reminded to engage regularly with people during their long periods of detention because people do not remember everything they have been told during their induction. This year again, we observed people who would have benefited from a reminder of what is available to them in the holding rooms.
Other
Bronzefield (2024)
What plans does the prison have to prioritise prisoner/key worker meetings for those prisoners who have been identified as most likely to benefit from them? (5.3)
Governor / Director
Whitemoor (2021)
Will the prison service please review urgently the use of specialised units in order to ensure that better and speedier arrangements can be made for prisoners whose needs are difficult or impossible to meet in a prison like Whitemoor? This would avoid the sad spectacle of men languishing for months at a time in demoralising and degrading conditions.
HMPPS
Stafford (2021)
Given the many negative comments of the Residents’ Survey regarding staff/resident relationships will the Governor put in place an action plan that is aimed at rectifying these issues?
Governor / Director
Liverpool (2021)
The role of the key worker should be developed, particularly in supporting prisoners who find it difficult to access prison systems.
Governor / Director
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That a compass to ascertain the direction of Mecca be available in all HRs and the STHF (see concern (k), above), together with a jug for water ablutions. However, a sign on the wall pointing to Mecca would remove the need for compasses
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That a translation device, such as Babel, giving information in a variety of different languages for the hard of hearing, or some other text relay service, be provided for all HRs and the STHF.
Home Office
Peterborough (Women) (2022)
The Board would like to see the restitution of a robust key work system whereby women are aware of this support and know their assigned key worker.
Governor / Director
Norwich (2022)
The Board asks the Governor to provide information on plans for maintaining the focus on decency and provision of basic essentials.
Governor / Director
Norwich (2022)
As the outside community learns to live with Covid, can HMPPS please outline what steps will be taken to return the prison to a more normal regime which would enable rehabilitation and more humane conditions?
HMPPS
Garth (2022)
Throughout this year the key worker scheme has not worked effectively because of staff shortages and consequent cross deployment. This should resume as quickly as possible.
Governor / Director
Foston Hall (2022)
The suspension of consistent and regular planned contacts by key workers, in line with offender management in custody requirements, thereby reducing rehabilitative and support work with prisoners (see paragraph 5.3.4)
Governor / Director
Stoke Heath (2023)
Can the key worker role to support offender managers in their work for all prisoners be made a priority in the future?
Governor / Director
Preston (2023)
The key worker programme should be increased so as to operate at its designed level.
Governor / Director
Humber (2023)
The Board, in particular, hopes that the key worker scheme will return to the quality and effectiveness we identified prior to the Covid pandemic. The Board acknowledges the difficulties caused by the regular turnover of prisoners but firmly believes an effective key worker programme is vital for a safe and effective establishment.
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that these interviews be conducted in a confidential space with more time and care taken to build trust and thereby encourage full disclosure.
Other
North East Midlands, Yorkshire & Humber STHF (2024)
We repeat the recommendation that all arrival interviews should be conducted in the purpose-built interview room in the facility, with privacy and with participants seated in comfort and speaking at eye level. For the reasons outlined in the evidence section (see section 4.1.1) we do not regard the ‘partial acceptance’ of this recommendation last year – namely by offering a …
Other
Haverigg (2024)
Concerns persist around prisoners’ unwillingness, or reported reluctance, to reach out for support when needed. The Board is encouraged by local steps taken to help address this issue and to reassure prisoners, but we recommend that a strong focus is maintained in this key area.
Governor / Director
Bullingdon (2024)
What steps will the Governor take to address the significant decrease in key working?
Governor / Director
Wayland (2025)
The Board would like to suggest that Practice Plus seriously consider running a survey of their own amongst prisoners to test for themselves the themes we have bulleted above, and also, as a response to the themes we have identified, to consider providing a clear confirmation of the diagnosis made and treatment to be provided after a consultation so the …
NHS / Healthcare Provider
Norwich (2025)
There are currently no ‘baby bonding’ sessions (aimed at introducing prisoners to newborn babies) for prisoners on the category B site, following the removal of facilities in 2023. When will these important sessions be reinstated?
Governor / Director
Cardiff IMB (2025)
Sut mae'r carchar yn bwriadu gwneud ymweliadau'n fwy cynhwysol i garcharorion ac ymwelwyr niwrowahanol?
Governor / Director
Woodhill (2020)
To continue efforts already being made through the Woodhill Growth Project to create a culture where the wellbeing and progression of prisoners is the prime consideration for staff.
Governor / Director
Yarl’s Wood (2021)
The Board continues to observe that many detained persons, particularly those detained under RSTHF rules, do not fully understand where they are or what will happen to them and at times have become frustrated about the length of their detention. The Board acknowledges that the large numbers of cross-Channel migrants have presented the centre with many challenges that have been …
Governor / Director
Yarl’s Wood (2021)
Vulnerable adults continue to be detained. The pilot scheme Community Action Pilot, Action Access exploring alternatives to detention has produced positive results. The Board recommends that the measures undertaken which improved the health and wellbeing outcomes for vulnerable persons are incorporated into case worker detention evaluation and centre operational procedure instructions for these persons.
Home Office
Thorn Cross (2021)
Thorn Cross is now taking prisoners who are serving longer sentences and who have longer to go to their possible release date. It is now possible for a prisoner to move from a high security prison straight to the open estate. In our view this is unfair on such prisoners who struggle to adapt and need a great deal of …
HMPPS
Thameside (2021)
The Board would like to see the same concentrated focus on improving the quality of the daily lives of prisoners where these can be influenced by the actions of staff, especially in the residential areas. IMB members regularly observe how poor communication between managers can stifle improved outcomes for prisoners, and how lack of empathy or thought can rob them …
Governor / Director
Swaleside (2021)
The inequality of opportunity for MCOSO and vulnerable residents still needs to be addressed, despite progress made in that direction. (see sections 5, 5.4 and 5.5)
HMPPS
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That a calendar of notable religious festivals be placed, and be maintained, in each HR and the STHF, and shared with all relevant parties including UKBF officers and C&C DCOs.
Home Office
Gartree (2021)
Can the Governor confirm that there is a simple and clear system in place to ensure that prisoners are able to understand exactly what property they can have in possession and in storage and what additional items they are allowed to order (from approved suppliers) and/or have sent in, and that staff are fully trained to support them with this …
Governor / Director
Gartree (2021)
Will the Governor ensure that all new arrivals are provided with a cell which contains all basic items of furniture and that they are given the clothing and any items they need on arrival at Gartree?
Governor / Director
Cookham Wood (2021)
What will be done to improve the opportunities for boys of all faiths to attend collective/collegiate worship?
Governor / Director
Wayland (2022)
The Board recommends to the Governor that greater training effort is made to upskill staff who are in daily contact with prisoners so that they are competent and confident to respond to prisoners who are seeking their help and, also, to proactively interact with prisoners to create the atmosphere and relationships where such interactions can take place.
Governor / Director
Rye Hill (2022)
The difficulties surrounding appropriate arrangements for end-of-life care and compassionate release, imposed by current HMPPS facilities and procedures, impact HMP Rye Hill disproportionately because of the higher than average age profile of the prisoners held. The current procedures do not seem to facilitate humane treatment of these prisoners.
HMPPS
Swaleside (2023)
The Board remains concerned about the impact of the recently introduced Offender Flow and Allocation system. Swaleside is a category B trainer in the LTHSE but is now receiving younger prisoners with shorter sentences. This is detrimental to the stability of the prison and the well-being of older, longer sentenced prisoners. The change should be re-examined and the benefit examined …
HMPPS
Moorland (2023)
Can there be a review of how the incentives system might be adapted so that prisoners perceive it as less punitive and more motivating?
Governor / Director
Lewes (2023)
Will the Governor work towards a restoration of the key work scheme to at least pre Covid-19 standards?
Governor / Director
Bristol (2024)
Key working is focused on the high-risk cohorts of prisoners. Will key working be available for all prisoners in the coming year?
Governor / Director
Wealstun (2025)
How will the Governor ensure that key workers sessions are provided for each prisoner and raise their profile?
Governor / Director
Lancaster Farms (2025)
When will the Governor increase the effective use of key working at the prison, with demonstrable targets and outcomes?
Governor / Director
Coldingley (2025)
The Prison Service should implement a replacement for the Sycamore Tree restorative justice programme.
HMPPS
Bedford (2025)
Will the Governor confirm that this [review rules in respect of clothing for visitors and the amount of money that can be brought in] will happen?
Governor / Director
Bedford (2025)
Can the Governor confirm that this [induction supported by a simple leaflet with key messages] will be delivered?
Governor / Director
Bedford (2025)
Will HMPPS confirm that this [consistent approach across all prisons in respect of clothing guidance for visitors and in respect of the amount of money that visitors can spend during visits] will be reviewed?
HMPPS
Bedford (2025)
Can HMPPS confirm when Launchpad will be introduced?
HMPPS
Bronzefield (2025)
How the prison plans to prioritise prisoner and key worker meetings for those who have been identified as most likely to benefit from them (5.3)?
Governor / Director
Berwyn (2025)
We are still receiving reports from prisoners saying that they do not know who their key worker is.
Governor / Director
Lancaster Farms (2022)
To ensure that contact between prisoners and their key workers becomes more effective.
Governor / Director
Norwich (2020)
Securing the ethos of enabling environments
Governor / Director
Norwich (2020)
maintaining the focus on decency, and particularly the ‘basics’
Governor / Director
Health Investigations (2)
Independent investigation into the care and treatment of Mr L — Rec 2
The Trust must ensure that staff take responsibility for issuing formal invitations to all those they believe should be present at a Care Programme Approach meeting, or document discussions where this intention is changed
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must ensure that appropriate support is given to clients wishing to apply for self directed support funding, who are known to have gambling habits.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Article 2 Learning Points (3)
— LP 5
I recommend that the Governor of HMP Ranby is asked: to note the absence of case notes or other evidence of constructive engagement with WA; to consider what practical arrangements are now in place at Ranby to cultivate positive interaction between staff and prisoners and whether more can be done; …
The Governor (HMP Ranby)
— LP 17
To make better use of pre‐existing information, we recommend that psychiatric assessment guidelines used on HMP Pentonville’s Healthcare unit reference the need to source and consider the results of medical and psychiatric assessments that may have been conducted by other institutions.
PPG
Accepted
— LP 12
We recommend that HMP Pentonville’s Healthcare unit reviews its use of ‘Special Observation forms’ and clarifies what value, if any, they are adding to the care and management of a prisoner who is on an observation regime.
PPG
Accepted
Detention Investigations (2)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R30
Pregnant residents should be allowed to eat their meals away from the main dining rooms without having to obtain permission from healthcare staff.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R9
Managers undertaking the current staffing review should address the question of how staff can best be given time to engage with residents and meet their emotional as well as practical needs.
Immigration Detention
PHSO Casework Decisions (215)
P-001097 — University Hospitals Sussex NHS Foundation Trust
Mrs U complains sedation was not used as planned for a joint injection procedure and she was not given the opportunity to cancel the procedure to come back another day when sedation would be available.
NHS in England
Partly Upheld
Aug 2021
P-001233 — Buckinghamshire Healthcare NHS Trust
Ms T complains about aspects of the care provided to her partner, Mr S, at the Trust. Ms T also complains about a lack of communication with her, and a lack of compassion in the end of life care for Mr S.
NHS in England
Upheld
Dec 2021
P-001329 — The Dudley Group NHS Foundation Trust
Mrs O complains that the Dudley Group NHS Foundation Trust did not administer her late husband's medication correctly, did not monitor his nutrition and made him use continence pads.
NHS in England
Mar 2022
P-003898 — Guy’s and St Thomas’ NHS Foundation Trust
Mrs P complains about an endoscopy procedure saying she was not given any pain relief, the Trust did not lubricate the endoscope and when she signalled for the procedure to stop, she was held down and it continued.
NHS in England
Sep 2023
P-002650 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr and Miss U complain about the care and treatment the Trust gave to their father. They say doctors made a DNACPR decision against the family’s wishes and his religious beliefs, staff did not provide enough information and updates and staff were rude, obstructive and unprofessional.
NHS in England
May 2024
P-002752 — A practice in the City of Derby area
Mr and Mrs R complain about the care and treatment the Trust provided during Mrs R's pregnancy and the birth. They complain the staff did not direct Mrs R to services, it did not support her to write a birth plan and staff did not tell her what was happening, …
NHS in England
Partly Upheld
Jul 2024
P-003285 — Warrington and Halton Hospitals NHS Foundation Trust
Miss E complains about the Trust’s treatment during her labour in October 2021. She complains staff ignored her wishes and gave her medical procedures without her consent.
NHS in England
Upheld
Jul 2024
P-002926 — University Hospitals Birmingham NHS Foundation Trust
Miss I complains about the care and treatment given to her father in 2021. Miss I complains her father was able-bodied when he went into hospital, but when he left he was disabled and he died shortly after. She also says the family felt pressured into accepting a Do Not …
NHS in England
Sep 2024
P-003124 — Mid Yorkshire Teaching NHS Trust
Mrs N complained about care the Trust provided to her late mother for her leg blisters. She also complained the Trust would not let her stay with her mother at the end of her life.
NHS in England
Upheld
Nov 2024
P-003297 — Royal Devon University Healthcare NHS Foundation Trust
Mrs E complains the Trust did not give her information about her son’s condition, discharged him when he was not well enough and failed to arrange follow up care.
NHS in England
Partly Upheld
Jan 2025
P-003295 — South Tyneside and Sunderland NHS Foundation Trust
Miss U complains the Trust did not provide her mother with adequate hydration in October 2021. Miss U also complains the Trust did not communicate with her regarding its Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision.
NHS in England
Upheld
Jan 2025
P-003798 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complains about her father's care in 2021. She says the Trust did not listen to their concerns or arrange regular BSL interpreters to help with his needs.
NHS in England
Partly Upheld
Mar 2025
P-003480 — A dental practice in the Torbay area
Mr P complains the Practice removed all his teeth against his will and did not give him any other options.
NHS in England
Apr 2025
P-003942 — Oxford University Hospitals NHS Foundation Trust
Ms T complains about care Mr R received at a hospital between March 2020 and December 2020. She complains the Trust did not offer appropriate treatment for Mr R’s prostate cancer, did not provide physiotherapy treatment and communicated poorly about a significant diagnosis.
NHS in England
Upheld
Sep 2025
P-004165 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mr W complains that his aunt, Mrs O, was incorrectly put onto end-of-life care without any consultation with her family, and that she received a substandard level of care. Mr W also complains about the clinical teams level of communication with him, and about the way his complaint was handled.
NHS in England
Oct 2025
P-004368 — East Suffolk and North Essex NHS Foundation Trust
Mrs R complains about the Trust's care and treatment of her mother, Mrs L. She also complains the Trust did not consult her or keep her informed despite the fact she had power of attorney.
NHS in England
Nov 2025
P-004377 — Harrogate and District NHS Foundation Trust
Mr Y complains on behalf of his son about Harrogate and District NHS Foundation Trust. He said the Trust incorrectly discharged his son without treatment in November 2022 and did not accept the opinion of an private physiotherapist and an osteopath.
NHS in England
Nov 2025
P-004394 — South London and Maudsley NHS Foundation Trust
Ms J complains the Trust did not adhere to her reasonable adjustment requests during her psychological assessment process and produced a flawed assessment report. She also complains the Trust did not respond to her complaint appropriately or in a timely manner.
NHS in England
Dec 2025
P-004400 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mr C complains about the treatment and care provided to his father by the Trust between October and December 2023 when he was admitted to hospital. He complains about frequent ward moves, lack of appropriate supervision and poor communication.
NHS in England
Dec 2025
P-004784 — A practice in the Oadby and Wigston area
Ms A says the Practice placed her mother, Mrs X, nil by mouth on 14 November 2022 without a proper assessment and left her facing a potential five day wait for a SALT review. She reports that the Practice communicated poorly and took too long to respond to her complaint. …
NHS in England
Upheld
Feb 2026
P-004765 — A dental practice in the Hounslow area
Miss A complains the Practice carried out dental work without adequate pain relief and cut her mouth.
NHS in England
Jan 2026
P-001066 — University Hospitals Sussex NHS Foundation Trust
Mrs E complains that Brighton and Sussex University Hospitals NHS Trust (the Trust) left her for 12 days without treatment. She says she experienced shortness of breath on and she did not receive a CT scan until 2weeks later which confirmed she had a compressed lung. She complains that whilst …
NHS in England
Upheld
May 2021
P-001165 — Royal United Hospitals Bath NHS Foundation Trust
Mrs G complained about the Trust’s care and treatment of her husband when he was in hospital in the period prior to his death. She also complained he was not offered an interpreter.
NHS in England
Upheld
Oct 2021
P-001175 — North Middlesex University Hospital NHS Trust
Miss A complained the Trust did not provide appropriate care and treatment to Mr A for his bed sores and did not communicate with her properly.
NHS in England
Upheld
Oct 2021
P-001314 — The Rotherham NHS Foundation Trust
Mrs O complains about her husband being put on palliative care without consent
NHS in England
Feb 2022
P-001509 — The Royal Wolverhampton NHS Trust
Miss L complains about the care and treatment she and her son received from the Trust. She complains the doctor did not listen to her when she said her son was dehydrated, and the doctor did not physically examine her son.
NHS in England
Aug 2022
P-001832 — Cambridge University Hospitals NHS Foundation Trust
Ms V complains about the Trust's care and treatment of her son in April 2018. She complains it did not put the right processes in place, did not communicate with her or involve her in the care planning.
NHS in England
Nov 2022
P-001628 — A medical practice on the Isle of Wight
Mrs T complains the Practice delayed restarting her vitamin B-12 injections after COVID-19 restrictions were lifted. She says the delays were against clinical guidance and the Practice gave different explanations to her about its service. She also complains it did not involve her in decisions about her care.
NHS in England
Nov 2022
P-001619 — East and North Hertfordshire NHS Trust
Ms KN complains on behalf of her mother, Mrs K, about the Trust's care and treatment in the A&E department. She complains Mrs K was vulnerable and did not get good care.
NHS in England
Upheld
Nov 2022
P-001717 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr A complains about the Trust's care and treatment of his fiancée, Ms E. He complains about the communication and its decision-making regarding her anorexia and autism.
NHS in England
Partly Upheld
Jan 2023
P-001713 — Liverpool University Hospitals NHS Foundation Trust
Mrs U complains the Trust delayed treating her husband, did not involve the family in decisions about care and it did not keep the family informed.
NHS in England
Partly Upheld
Jan 2023
P-001820 — A practice in the Derbyshire area
Ms R complains a nurse at the Practice did not offer her father a face to face appointment, provided inappropriate treatment during a telephone consultation, and did not provide any follow up care.
NHS in England
Feb 2023
P-001826 — A practice in the Calderdale area
Mrs A complains the Practice diagnosed her mother over the phone many times but her condition did not improve. She also complains the Practice's communication was poor.
NHS in England
Feb 2023
P-001818 — A practice in the Somerset area
Miss O complains the Practice was not clear during an asthma review. She also says it did not listen to her concerns about eczema, it did not look at a lump on her neck, its communication was not clear and it was difficult to contact.
NHS in England
Feb 2023
P-001876 — A dental practice in the Kingston upon Thames …
Mr R complains the Practice cemented a crown in place without letting him check it first. He also complains that after fitting the crown, the Practice told him it cannot be removed.
NHS in England
Upheld
Mar 2023
P-001908 — Northern Care Alliance NHS Foundation Trust
Mrs C complains the Trust missed opportunities to investigate her sister's symptoms. She said it did not put a care plan in place after a consultation and a member of staff made hurtful comments after her sister died.
NHS in England
Mar 2023
P-001900 — The Chaseley Trust
Mrs R complains about the care and treatment provided by a care home funded by the Trust. She says it gave her too much antibiotic cream for her eyes, did not give her eye drops properly and did not communicate details of her hospital appointment.
NHS in England
Mar 2023
P-001882 — South Warwickshire NHS Foundation Trust
Mrs U complains the Trust added a 'Do Not Attempt to Resuscitate' (DNAR) notice to her husband's records without telling her. She also complains it failed to do blood tests and to give the correct medication when needed, and it did not tell her when her husband died.
NHS in England
Mar 2023
P-001884 — A hospital in the Sheffield area
Mr I complains the Hospital did not manage his pain well after a knee replacement operation in September 2021. He is also unhappy with the Hospital's complaint handling.
NHS in England
Mar 2023
P-001863 — Leicestershire Partnership NHS Trust
Ms L complains the Trust's district nursing team did not give her mother medication and did not respond when the family tried to contact it.
NHS in England
Mar 2023
P-001894 — Manchester University NHS Foundation Trust
Ms R complains the Trust failed to manage her mother’s pain medication in the days leading up to her death. She also says the Trust’s poor communication led to her feeling confused about her mother’s care.
NHS in England
Mar 2023
P-001867 — The Princess Alexandra Hospital NHS Trust
Mrs E complains about the Trust's palliative care and treatment of her son in April 2021. She complains about its communication, pain management and how available its doctors were.
NHS in England
Mar 2023
P-001930 — United Lincolnshire Hospitals NHS Trust
Mr L complains the Trust did not manage his wife’s vulnerability or treat her conditions appropriately. He also complains he was not consulted as her carer, or allowed to visit her until she was dying.
NHS in England
Apr 2023
P-003885 — A practice in the Kent area
Mrs O complains the Practice prescribed end-of-life medication to her husband without explaining why.
NHS in England
Jul 2023
P-003877 — Nottingham University Hospitals NHS Trust
Ms T complains the Trust would not let the family support her mother in hospital and it did not have a coordinated care plan. She says the Trust did not meet her mother’s individual needs and would not let her be discharged to the care of the family.
NHS in England
Partly Upheld
Jul 2023
P-003284 — University Hospitals Birmingham NHS Foundation Trust
Miss O complains about the treatment her sister received in June 2021. Miss O complains the Trust failed to get consent and instead forced her sister to be catheterised. She also complains about delays in the Trust’s complaint handling.
NHS in England
Upheld
Sep 2023
P-003873 — Guy's and St Thomas' NHS Foundation Trust
Mrs E complains the Trust refused a reasonable adjustment and did not let her stay on the ward with her severely disabled daughter overnight.
NHS in England
Sep 2023
P-003896 — Cambridge University Hospitals NHS Foundation Trust
Mr A is complaining about an operation he had on 20 January 2022 to remove an obstruction from his nose, which was not successful. After the operation his nose would not stop bleeding and the consultant said they could try another operation. Mr A complains that from start to finish …
NHS in England
Sep 2023
P-002288 — Northern Lincolnshire and Goole NHS Foundation Trust
Mrs J complains the Trust wrongly accepted her brother had capacity to state his preferences about care at the end of his life. She says the Trust then used this to end his treatment instead of involving the family in the decision.
NHS in England
Nov 2023
P-002386 — Lancashire and South Cumbria NHS Foundation Trust
Mr N complains about his diagnosis and the lack of patient-centred support.
NHS in England
Dec 2023
LGO / SPSO Decisions (60)
21-016-787 — Kent County Council
Summary: Mr X complains the Council’s care provider, Expertise Homecare (Ashford), failed to meet his late mother’s needs, putting her at risk of harm. His mother did not always receive person centred care and was put at risk of harm by some of her care workers. This caused avoidable distress …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-004-508 — Kent County Council
Summary: Mr X complains the Council failed to meet his son’s care and support needs when it prevented him from accessing more than one day service because of COVID-19, which had an adverse impact on his well-being. The Council failed to assess all the risks and failed to consider what …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
23-015-685 — Milton Keynes Council
Summary: Mr X complains the Council decided without his involvement that it would place his disabled son, P, in residential care. However, that did not happen, and P is now settled in a day service placement of his parents’ choice, funded through the NHS. There is no evidence that P …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-018-947c — Allison House (23 018 947c)
Summary: Ms Y complained that professionals failed to understand her mother’s personality and wrongly determined she lacked capacity. Ms Y said this led to a decision to transfer her mother to a nursing home which caused her distress. In addition, she said it led to a hospital and a nursing …
LGO (Local Government & …
Health
Not Upheld
Jul 2024
23-018-947a — North Tees and Hartlepool NHS Foundation Trust (23 …
Summary: Ms Y complained that professionals failed to understand her mother’s personality and wrongly determined she lacked capacity. Ms Y said this led to a decision to transfer her mother to a nursing home which caused her distress. In addition, she said it led to a hospital and a nursing …
LGO (Local Government & …
Health
Not Upheld
Jul 2024
NIPSO-202001016 — Western Health and Social Care TrustNorthern Ireland Hospice
The daughter of an elderly cancer patient complained that her syringe driver was removed in the days before her death, causing her to experience unnecessary pain.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2024
21-012-160 — Bournemouth, Christchurch and Poole Council
Summary: Mr X complains the Council has failed to make reasonable adjustments when communicating with him, resulting in avoidable distress and unnecessary time and trouble in pursuing his concerns. The Council has accepted its failings and has taken steps to ensure Mr X receives the service he needs in future. …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
22-004-316 — South Gloucestershire Council
Summary: We will not investigate this complaint about the Council illegally keeping Mr B from caring for his wife, lying, and disrespecting him. This is because
LGO (Local Government & …
Adult Care Services
Jul 2022
21-011-711d — CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-711c — Woking and Sam Beare Hospice and Wellbeing Care …
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
21-018-113 — London Borough of Hounslow
Summary: Mr X complained the Council failed to ensure his family are suitably housed given Mrs X’s disabilities. The Council was not at fault for the way it dealt with Mr X’s housing priority, housing allocation and care needs assessment. The Council was at fault as it failed to consider …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
22-002-110 — Herefordshire Council
Summary: Miss C complains that the Council said it would move her daughter, Miss D, to a care home closer to the family home when a place became available but refused to do so. The Council was at fault for poor communication with Miss C. This fault caused injustice as …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
22-002-090 — Northumberland County Council
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-006-318 — South Gloucestershire Council
Summary: There were communication failures in respect of Mr X’s needs and a failure to understand new practices which led to a delay in moving him to a nursing home in his home area. There were also failures to communicate properly with Mr X’s wider family. The Council agrees to …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-012-707 — Gloucestershire County Council
Summary: Mrs X complained about contact restrictions between her relative Ms Y and Ms Y’s mother Mrs Z which the Council continued to impose after Ms Y left a care home. The Council was at fault for failing to clarify the nature of the restrictions and the actions needed to …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
23-004-023a — Carpathia Grange (23 004 023a)
Summary: We have found fault with pressure care management and record keeping by a care home. On balance we do not consider this caused harm, but it has led to uncertainty around pressure care and the speed of recovery. The Council and the care home accepted our recommendations, which included …
LGO (Local Government & …
Health
Upheld
Jun 2024
23-013-439 — North Yorkshire Council
Summary: Ms X complained about the handling of her Disabled Facilities Grant (DFG) application. She says the proposed adaptations to her property are not fit for purpose and do not create sufficient space for her family. Mrs X complained the Council did not consider her family holistically or take account …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-010-073 — North East Lincolnshire Council
Summary: Mr X complained Care Plus Group Ltd, acting on behalf of the Council, unsafely discharged his late father Mr Y from residential respite care to his home without proper assessments and care planning. There was fault in the assessment and care planning process, which caused distress to Mr Y …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-023-076 — Brighton & Hove City Council
Summary: Mx X complains for Ms Y the Council was at fault in the way it provided her with care and support. We have found no evidence of fault in the way the Council considered these matters. So have completed our investigation.
LGO (Local Government & …
Adult Care Services
Not Upheld
Dec 2025
PSOW-202105742 — Betsi Cadwaladr University Health Board
Mrs J complained about the actions of the Learning Disability Team (“the LD Team”) of the Health Board in response to her request to provide assistance to move her sister, Miss M, from the upstairs of her home to a new home with Mrs J and her family in April …
PSOW (Public Services Om…
Health
Upheld
Dec 2022
21-010-549 — London Borough of Hammersmith & Fulham
Summary: Miss X complained about the support the Council provided when she was moving home. Miss X also complained the Council refused to carry out a review of her care plan. Miss X says this has affected her mental and physical health. We find fault with the Council for a …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
20-012-439 — Reading Borough Council
Summary: Mr Y complains about the Council’s handling of his reports of noise nuisance from his neighbour. Mr Y says this caused stress and distress, and affected his ability to sleep and work. We do not find fault in the Council’s decision that there was no evidence of a statutory …
LGO (Local Government & …
Environment And Regulation
Upheld
Jun 2022
21-017-741 — Leeds City Council
Summary: Ms B complained that, since October 2021, the Council had not adhered to a communications protocol agreed with her. We found there were several occasions when the Council failed to comply with the protocol causing Ms B distress and inconvenience. In recognition of the injustice caused, the Council has …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-001-113 — Medway Council
Summary: Mrs X complained that the Council failed to effectively search for a suitable care placement for her mother, Mrs P. She says the family felt pressured to accept an unaffordable placement. The Council undertook a thorough search for a placement for Mrs P. However, ultimately, it was at fault …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-017-826 — Bournemouth, Christchurch and Poole Council
Summary: Mrs X complained that the Council communicated poorly with her and her family about paying for her mother’s care, finding and arranging assessments at care homes, and when her mother was in hospital. Mrs X said the delay arranging a residential care home placement resulted in her mother going …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
23-013-092 — London Borough of Lewisham
Summary: Ms X complained the Council reduced care and support hours for her adult son, Mr Y, without any reassessment of his needs or a review of his care and support plan when he went into supported living accommodation. The Council was at fault which caused Ms X and Mr …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-008-582 — London Borough of Tower Hamlets
Summary: Mrs X’s representative complained about the cancellation of a cleaner; failure to find a new personal assistant; failure to consider a requested reasonable adjustment and failure to refund her client contribution. She says this has caused stress, anxiety and worsened her health conditions. There is no evidence of fault …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-020-031 — Worcestershire County Council
Summary: We will not investigate this complaint about the Council’s assessment of Miss X’s mental capacity and its decision to authorise a Deprivation of Liberty Safeguards (DoLS). The Council is reviewing the assessment and further investigation by us would not lead to a different outcome. If Miss X remains unhappy …
LGO (Local Government & …
Adult Care Services
May 2024
23-020-833 — London Borough of Lewisham
Summary: We will not investigate this late complaint about the Council’s decision to move Mr Y to emergency accommodation in 2022. There is not a good reason for the delay in the matter being brought to our attention.
LGO (Local Government & …
Adult Care Services
May 2024
23-013-280 — Brighton & Hove City Council
Summary: Ms M complained the Council failed to address her concerns about the adult care services her son, Mr S, receives. The Council is at fault for delay reviewing Mr S’s care plan and failing to carry out a transport assessment.
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
23-014-185 — Leeds City Council
Summary: The Council delayed in completing Mr X’s support plan following a Care Act assessment, failed to advise him at the outset that direct payments could not be used to pay a relative to act as his personal assistant because she was living in the same household and reversed its …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-006-417 — Dudley Metropolitan Borough Council
Summary: We will not investigate Mx Y’s complaint about how the Council completed a review of their adult social care needs. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-017-927 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about Council’s decision to limit Mr X’s participation in the co-production board. The Council has since met with and written to Mr X to resolve his ongoing concerns.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-017-462 — Derby City Council
Summary: Miss X complained about a lack of support to complain about a care worker, and about a failure to allocate a named social worker to her case. We will not investigate this complaint because it is unlikely that an investigation would find evidence of fault in the Council’s actions.
LGO (Local Government & …
Adult Care Services
Jun 2025
24-012-888 — Hampshire County Council
Summary: Ms Y, on behalf of Mr X, complained about the Council’s handling of his care and support needs, as well as its failure to oversee the completion of a housing adaptation, leaving the work unfinished. We find the Council at fault for failing to respond to contact, properly consider …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-022-964c — South West Yorkshire Partnership NHS Foundation Trust (24 …
Summary: Mrs X complained about the care provided to her daughter Miss Y when she had a mental health crisis. The events occurred in 2022. We will not investigate the complaint because it is out of time.
LGO (Local Government & …
Health
Jul 2025
24-022-964b — NHS West Yorkshire ICB - Calderdale (24 022 …
Summary: Mrs X complained about the care provided to her daughter Miss Y when she had a mental health crisis. The events occurred in 2022. We will not investigate the complaint because it is out of time.
LGO (Local Government & …
Health
Jul 2025
24-022-964a — Beechwood Medical Centre (24 022 964a)
Summary: Mrs X complained about the care provided to her daughter Miss Y when she had a mental health crisis. The events occurred in 2022. We will not investigate the complaint because it is out of time.
LGO (Local Government & …
Health
Jul 2025
25-002-334 — Royal Borough of Kingston upon Thames
Summary: We will not investigate this complaint about how the Council supported Miss X as a care leaver. This is because we could not add to any previous investigation by the Council and Miss X’s injustice caused by any fault there was, has already been remedied. In addition, we cannot …
LGO (Local Government & …
Adult Care Services
Aug 2025
23-013-813a — Livewell Southwest (23 013 813a)
Summary: Mrs X complained on behalf of the Y family that Plymouth City Council and Livewell Southwest did not put support in place, recommended by an independent social worker. We consider they missed opportunities to consider Miss Y’s ability to make decisions about her support. The Council delayed arranging a …
LGO (Local Government & …
Health
Upheld
Sep 2025
25-003-962 — Surrey County Council
Summary: We will not investigate this complaint about a best interests decision which determined where Miss B’s son should live. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Oct 2025
25-003-237 — Liverpool City Council
Summary: We will not investigate this complaint about a carer’s assessment completed by the Council and the support it then offered. There is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Nov 2025
24-021-321 — London Borough of Waltham Forest
Summary: The Council was at fault for poor communication and a failure to properly review Mr X’s care needs after his reablement package ended. It was also at fault for the significant delay in responding to his complaint. The Council has agreed to apologise to Mr X and make a …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2025
25-003-785 — Kingston Upon Hull City Council
Summary: We will not investigate this complaint about funding of adult social care. We are satisfied with the actions the Council has taken in response to the complaint. It has accepted fault, apologised for the distress caused and waived over £400 of client contribution. The Council has explained its calculations.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2025
24-003-905 — East Riding of Yorkshire Council
Summary: Mrs X complained that the Council failed to take adequate action when she raised concerns about her late mother’s health and living conditions despite having knowledge of her history of mental health problems and hoarding behaviours. We found no grounds to criticise the Council’s actions. However, it was at …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
201103669 — Tayside NHS Board
Mrs C made a number of complaints about the board's care and treatment of her husband (Mr C). Mr C had been diagnosed with rectal cancer (cancer of the lower part of the large bowel) and liver metastasis (cancer that spreads to other parts of the body). Mrs C said …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2013
NIPSO-201916274 — GP
We investigated whether an increase in a man’s prescription caused him to attend hospital the following day. We found the Practice’s increase in the dose fell within the prescribed limits.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Mar 2024
21-016-545 — East Riding of Yorkshire Council
Summary: Mr X complained about the way the Council handled his mother, Mrs Y’s care and finances. The Council failed to review Mrs Y’s care plan and package when concerns were raised for her wellbeing and failed to ensure care improved after it identified failings in the care provider. The …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-016-886 — Liverpool City Council
Summary: Ms X complained the Council failed to review or properly communicate with her about her direct payments and support needs. Ms X says this has caused her anxiety, confusion and put her to the time and trouble of complaining. The Council was at fault for not reviewing or communicating …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-009-143 — Royal Borough of Greenwich
Summary: We will not investigate Mr B’s complaint about the Council contacting him when he told it not to. This is because
LGO (Local Government & …
Adult Care Services
Nov 2022