Outdated Emergency Preparedness Guidance
Outdated, fragmented, and overly long emergency preparedness guidance, lacking emphasis on recovery and identification of vulnerable people.
93 items
7 sources
5 inquiries
Source spread
Where this theme appears
Outdated Emergency Preparedness Guidance has been flagged across 7 independent accountability sources:
8 inquiry recs
34 PFD reports
33 committee recs
4 PPO recs
3 IOPC recs
5 NAO recs
6 IMB recs
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 (8)
P2-44 — Consolidate and update emergency preparedness guidance
Recommendation: The current guidance on preparing for emergencies is contained in several documents, all of which are unduly long and in some respects out of date. We recommend that the guidance be revised, reduced in length and consolidated in one document …
Gov response: The government accepts this recommendation. We will fully factor it into the outcomes of the resilience review. As a first step, we will publish the revised local responder guidance on 'Identifying and Supporting Vulnerable People' …
Accepted
In progress
MAI-123 — GM Resilience Forum tri-service plan reviews
Recommendation: The Greater Manchester Resilience Forum should oversee, at least every six months, a regular tri-service review of the Major Incident plans used by Greater Manchester Police, Greater Manchester Fire and Rescue Service and North West Ambulance Service. The purpose of …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-99 — Review licensing guidance on event healthcare
Recommendation: The Ministry of Housing Commuities and Local Government should review the guidance given to all licensing authorities on the decisions they make in relation to venues that hold events, and on what level of event healthcare services may be required …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-46 — Guidance on Major Incident plan review frequency
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should issue guidance for all police services on how often operational plans for responding to a Major Incident, including a terrorist incident, …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
HIDD-79 — Department of Health to review Circular 71, clarifying Major Incident declaration terms
Recommendation: The Department of Health shall review DHSS Circular 71 in consultation with emergency and medical services to reflect all lessons learned but in particular in relation to procedures for declaring a Major Incident. The Department of Health shall specifically require …
Unknown
CR16 — Mass rescue operation plan
Recommendation: HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, and public and external affairs.
Response Pending
CR5 — Mass Persons in Water Triage procedure
Recommendation: Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational response to a maritime search and rescue incident when the number of people requiring rescue exceeds the capability …
Response Pending
COVID-M2.10 — Pandemic Decision-Making Framework
Recommendation: The UK government and devolved administrations should set out in future pandemic preparedness strategies how decision-making will work in a future pandemic. This should include provision for COBR to be used as the initial response structure and set out how …
Gov response: No formal response published by this government.
Accepted
PFD Reports (34)
Jessica Ashton-Pyatt
Concerns: The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
Overdue
Janet Richardson
Concerns: The deceased fell into the sea during a rescue medical evacuation.
Response (Newmarket Promotions Ltd): Newmarket Promotions Ltd. states that they forwarded the Coroner's recommendations to their clients, however, disclaim responsibility as emergency procedures are the responsibility of the authorities.
Response (Cruise Maritime Services International Limited): CMSI states that they strongly believe that the Norwegian Rescue Service had appropriate procedures in place. However, they changed their procedures following the incident to prevent similar incidents from recurring, …
Overdue
Martin Daffydd Barker
Concerns: There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk to patient safety.
Response (North West Ambulance Service NHS Trust): The Ambulance Service clarified the difference between organised events and day-to-day operations, stating they cannot be the "gatekeeper" for NHS hospital standby numbers for private ambulance services. They suggest guidance …
Response (Department of Health): The Department of Health will share the case with the Care Quality Commission to consider whether access to emergency departments needs to be part of the inspection portfolio for independent …
Overdue
Lucy Moffatt
Concerns: Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.
Response (CQC): The CQC is reviewing its registration process to include specific questions on safety alerts, and piloting pre-inspection methodology to assess dissemination of safety alerts by providers.
Response (Department of Health): The Department of Health discussed the report with the CQC, who will take steps to improve the implementation of Safety Alerts, including Department of Health Alerts.
Responded
Davina Tavener
Concerns: Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight cardiac arrest despite such equipment being available and simple to operate.
Response (IAA): The IAA notes the current practices of Irish air operators regarding AEDs and aircraft, and states that the Chief Executive of the IAA has written to the Chief Executive of …
Response (EASA): EASA acknowledges the concerns and will engage with Member States to reconsider the situation through analysis of available data, launching a first discussion at the next meeting with air operations …
Response (CAA): The CAA will raise the issue of mandatory medical equipment on aircraft, including defibrillators, at the Flight Operations Liaison Group, to obtain an industry view and assess whether operators should …
Responded
George Hines
Concerns: Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.
Overdue
James Robertson
Concerns: Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation pack lacked essential equipment.
Overdue
Nathan Charman
Concerns: The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.
Response (Durham County Council): Durham County Council reviewed the incident and has amended the Winter Maintenance Operational Plan to align gritting route 28 to the Low Pennines weather forecasting domain and to confirm that …
Responded
Zane Gbangbola
Concerns: Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the risk of harm.
Overdue
Joshua Smith
Concerns: Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.
Response (Maritime Coastguard Agency): The Maritime Coastguard Agency has updated guidance and modified training packages. All Coastguard tactical commanders attend JESIP courses and strategic commanders attend MAGIC courses; every officer completes online JESIP training. …
Response (Northumberland Fire and Rescue Service): Northumberland Fire and Rescue Service reaffirmed procedures for 999 calls, implemented joint working principles with blue light partners, and trained staff in JESIP. Future plans involve including HM Coastguard and …
Response (Northumbria Police): Northumbria Police and the North East Ambulance Service are considering expert advice from Mountain Rescue regarding phone tracking software. HM Coastguard is considering improving their Airwave capability to facilitate communication. …
Overdue
John Wilson
Concerns: The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post or follow-up visits, despite known increasing fire risk with product age.
Overdue
Mavis Reeves
Concerns: The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.
Response (FirstPort Retirement): FirstPort has separated the master key in the key safe and stored it prominently. They investigated installing Safelink and an emergency telephone line at the entry gate, but concluded neither …
Responded
Ellie Knowles
Concerns: A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar future events.
Overdue
Christopher McGuffie
Concerns: Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Response (Arriva): Arriva Rail North is developing a campaign using various media, providing bespoke training for customer service controllers and are looking to bring forward the planned installation of CCTV at Chester …
Responded
Matthew Lewis
Concerns: Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
Response (South Wales Police): South Wales Police have developed a procedure for call handlers that incorporates guidance highlighting the presumption that 'life is not extinct' in hanging scenarios. This procedure is now part of …
Response (College of Policing): The College of Policing will amend learning standards for contact management staff within the next month to reflect the importance of preserving life. They have also asked for a summary …
Responded
Saeid Hedayat
Concerns: West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking regular review or warning signs for known flood risks, despite available data and increased storm severity.
Response (West Sussex County Council): WSCC reviewed their risk assessment process, taking into account changes in risk level and now account for flood events and silt levels when arranging gully cleansing. They dispute the need …
Responded
Thomas Reilly
Concerns: The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.
Overdue
Flora Shen
Concerns: The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily on the public to notice and report track hazards, as CCTV cannot monitor all areas simultaneously.
Response (Office of Rail and Road): The Office of Rail and Road (ORR) acknowledges the report but states they do not have the power to take the actions proposed; they recommend the report be directed to …
Response (TFL): TfL and Keolis Amey Docklands will enhance the visibility of platform alarms and continue to work towards a possible trial of CCTV obstacle detection technology; they will also discuss platform …
Overdue
Gillian Davey
Concerns: The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Response (Maritime and Coastguard Agency): The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response.
Response (RNLI): The RNLI is revising plans to increase lifeguard cover on beaches, working with landowners and councils to confirm beaches and timings, with public announcements to follow.
Response (Maritime and Coastguard Agency): The MCA states they have no statutory responsibilities for beach safety, but continue to work with partners on safety campaigns, including a joint campaign with the RNLI; they are ready …
Responded
Michael Pender
Concerns: The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Response (RNLI): The RNLI is revising plans to provide lifeguard cover on additional beaches, working with landowners and councils to confirm beaches and timings for public announcement.
Response (Maritime and Coastguard Agency): The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response.
Response (Maritime and Coastguard Agency): The MCA reiterates its role in coordinating search and rescue, clarifies that it has no statutory responsibility for beach safety, and states that it will continue to work with partners …
Responded
Jan Klempar
Concerns: Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.
Response (Maritime and Coastguard Agency): The MCA outlines its role in coordinating search and rescue missions, clarifies it has no responsibility for beach lifeguards, and describes publicity campaigns with the RNLI to encourage personal responsibility …
Response (RNLI): The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for …
Responded
Anthony Williamson
Concerns: Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.
Response (Maritime and Coastguard Agency): The MCA confirms its search and rescue services were maintained during the pandemic, describes collaboration with Surf Life Saving GB, and states responsibility for beach safety lies with landowners.
Response (the RNLI): The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for …
Responded
Andrew Westlake
Concerns: Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.
Response (JET): Jet2.com has updated its Ground Handling Manual to include procedures for supporting vulnerable passengers, including contacting family/friends, embassies, or other services. Training will be updated using the case as a …
Response (CAA): The Civil Aviation Authority (CAA) will explore how to define vulnerable consumers, propose improvements to their treatment in the UK aviation industry, and increase engagement with industry. The CAA Executive …
Responded
Nicholas Winterton
Concerns: The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.
Response (UK Health Security Agency): PHE will update risk estimates for Mycobacterium chimaera infection and publish them by September 2021, cascading the information to healthcare professionals through clinical networks; they will forward the request to …
Overdue
Zainab Hashim and Tafaoul Abdulkarim
Concerns: Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.
Response (Stoke-on-Trent City Council): The Council already provides fire safety information in multiple languages and displays notices; they plan to increase targeted digital communication and explore displaying notices about requesting translated information and are …
Responded
Vinnie Dodds
Concerns: There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia lacks clarity on rare risks of foetal or maternal death.
Response (Dept of Health and Social Care): The response acknowledges the death and outlines current NICE guidance on managing large babies and gestational diabetes, noting an ongoing trial on inducing labour for predicted macrosomia.
Responded
Rita Britten
Concerns: Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are compromised, creates a significant safety risk.
Response (NHS England): NHS England notes the Coroner's concerns and is assured by the Resuscitation Council UK's response, stating that the specific circumstances are not within NHS England's direct statutory responsibility. The concerns …
Response (Resuscitation Council): The Resuscitation Council UK clarifies that its existing basic life support guidelines cover foreign body airway obstruction for all individuals and includes e-learning modules. They have assessed suction-based devices but …
Responded
Levi Alleyne
Concerns: Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked both bystander and emergency service safety and delayed life-saving treatment.
Response (Energy Networks Association): ENA has asked each DNO and TNO member company to check that emergency services have contact details and know how to respond to incidents; ENA will open dialogue with the …
Response (NHS England): NHS Digital explains the function and governance of NHS Pathways, noting that standard operating procedures and contact numbers are the remit of local service providers and do not fall under …
Response (AACE): AACE shared South Central Ambulance Service NHS Trust's updated SOPs, including a map and contact details for electricity Distribution Network Operators, across all NHS ambulance services. They are also discussing …
Response (Health and Safety Executive): HSE shared concerns with the Care Quality Commission (CQC) and Healthcare Inspectorate Wales (HIW), the Association of Police Health and Safety Advisors (APHSA), the National Police Chiefs Council (NPCC) and …
Overdue
Christine McDonald
Concerns: Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
Response (HM Prison and Probation Service): HMPPS launched a video in January 2024 demonstrating how staff should respond to a medical emergency, including the use of Code Blue and Code Red communications, which has been delivered …
Overdue
Samsam Ateye
Concerns: The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
Response (NHS England): NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports.
Responded
Champagauri and Dipak Bhatt
Concerns: Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and inconsistent risk assessment methodology.
Response (Hotpoint UK Appliances Ltd): Hotpoint states it will support the LFB/AMDEA initiative of digital identification and comply with any future industry-wide regulatory requirements. It will also work with government policy makers, regulators, fire services, …
Response (Association of Manufacturers of Domestic Appliances): AMDEA acknowledges the coroner's concerns and states its commitment to collaborating with stakeholders to enhance product safety. They also note that fire incident data for key appliances is collated annually …
Response (BSI Group): BSI acknowledges the coroner's concerns and explains its role in standardization. The CPL/61 committee considered the request to improve standards for condensate pumps and filters but needs more information regarding …
Response (North Yorkshire County Council): North Yorkshire Council, as primary authority for Hotpoint, states that testing was conducted on the part in question and that it passed all tests. They have arranged for further testing …
Response (Office for Product and Safety Standards): OPSS is seeking an update from BSI on the progress of a pilot project trialing a fire-resistant marking approach to enable identification of fire-damaged appliances and supporting their traceability.
Response (National Fire Chiefs Council): The National Fire Chiefs Council states that receiving information from manufacturers on replaced or recalled parts is not within their remit. They support the single recall register and advocate for …
Response (Home Office): The Home Office acknowledges the report but states it cannot provide a specific response due to a lack of detail regarding which aspects of information management need to change.
Response (Chartered Trading Standards Institute): CTSI acknowledges the coroner's concerns and describes its role in consumer protection and its support for OPSS. It highlights the need for a national approach to product safety and consumer …
Responded
Luke Albiston O’Donnell
Concerns: The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack of communication and media coverage on this danger.
Response (NFCC): NFCC supports fire and rescue services with prevention campaigns like Charge Safe, provides guidance on safe purchasing, and shares learning from incidents. The NFCC Chair has written to all Chief …
Response (OPSS): OPSS launched the Buy Safe, Be Safe campaign to raise awareness of e-bike and battery risks and is taking enforcement action against unsafe products. They are supporting the Product Safety …
Responded
Jean Langan
Concerns: The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe helicopter operations.
Response (Department for Transport): While hospitals are responsible for HHLS safety, the DfT is considering legislation to ensure safety at all HHLSs and will assist DHSC in developing options for an HHLS database.
Response (Department of Health and Social Care): DHSC states that NHS England now has the contact information for accountable managers at all Trusts operating HHLS and has worked with them to implement requests from Bristow's Helipad operator. …
Response (Sandwell and Birmingham West NHS Trust): The Trust amended the EMRT policy to clarify when EMRT calls are appropriate even with a DNACPR in place, communicated the updated policy to staff, and aligned wording with the …
Responded
Stuart Gilchrist
Concerns: Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving equipment.
Response (East Riding Council): East Riding Council confirms it does not have powers to specify equipment in first aid kits or publish guidance, instead signposting businesses to HSE guidance, and recommends the Regulation 28 …
Response (Health and Safety Executive): HSE outlines health and safety legislation regarding workplace first aid provision and clarifies that there is no requirement for employers to provide specific equipment such as anti-choking devices, advising that …
Overdue
Committee Recommendations (33)
#118 — Consider physical cash value in emergency preparedness and severe payment system outages
Recommendation: In discharging its responsibility for national security and resilience, HM Treasury must consider the value of physical cash in emergency preparedness. This may include recommending that cash is held by individuals in case of emergency, and considering what role cash …
Gov response: The Government agrees it is important to continually monitor the impact of how cash access is being tackled internationally, recognising it is not alone in experiencing a decline in cash use and that measures used …
Accepted
#19 — UK preparedness for acute AMR risks is strong initially, but scaling up remains challenging.
Recommendation: We also asked DHSC about the UK’s preparedness for addressing the chronic risk of AMR and the possibility of it becoming an acute risk. DHSC told us that the UK has a strong base which would make the initial response …
Gov response: 3.6 The government agrees with the Committee’s recommendation Target implementation date: Summer 2025 3.7 AMR has been incorporated in the 2025 National Risk Register as a chronic risk, as well as in the Chronic Risks …
Accepted
#18 — AMR is a chronic risk with potential acute threats, hindering sustained government focus.
Recommendation: The government categorises AMR as one of 26 ‘chronic’ risks facing the UK, which means that it poses a long-term, continuous challenge to the UK, as opposed to an ‘acute’ risk which is an immediate threat which may require an …
Gov response: 3.6 The government agrees with the Committee’s recommendation Target implementation date: Summer 2025 3.7 AMR has been incorporated in the 2025 National Risk Register as a chronic risk, as well as in the Chronic Risks …
Accepted
#22 — Government's hate crime action plan remains expired, missing strategic opportunity.
Recommendation: It is disappointing that the Government has not updated the hate crime action plan, which expired in 2020. The lack of an action plan is a missed opportunity to provide a coherent, cross-departmental strategy on tackling intersectional hate crime. (Conclusion, …
Gov response: 63. The recently published Protecting What Matters outlines the Government’s approach to improving social cohesion based on three key pillars: confident communities, focusing on pride in place and community initiatives; cohesive communities, focusing on integration …
No Published Response
#4 — Police forces were unprepared for high levels of violence during last summer's disorder.
Recommendation: The levels of violence seen across the country last summer were the worst since 2011. Police officers worked tirelessly to respond to the disorder and it was only through their efforts that more serious injury and property damage was prevented. …
Gov response: We are working with the police to ensure measures for the Police System Reform White Paper are suitably designed to tackle the policing challenges of the future. Separately, and focused specifically on their response to …
Accepted
#78 —
Recommendation: As a result, decisions on lockdowns and social distancing during the early weeks of the pandemic—and the advice that led to them—rank as one of the most important public health failures the United Kingdom has ever experienced. This happened despite …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#2 —
Recommendation: The Cabinet Office and Government Office for Science should update SAGE guidance to set out the role that SAGE will play in advising the Government’s long-term management of emergency scenarios. (Paragraph 34) Activation and operation of SAGE
Gov response: The responsibility for long-term management of emergencies (including prevention, contingency planning, response and recovery) sits with the accountable, policy- owning Government Departments and their respective Ministers in accordance with the principle of lead government department. …
Under Consideration
#2 —
Recommendation: Civilian agencies will inevitably require assistance in a crisis of this scale and there should be no stigma in seeking help from the Armed Forces. However, it is clear that preparations for a non-man-made threat such as an infectious disease …
Gov response: Defence support to other Government departments is channelled through the well- defined Military Aid to Civil Authorities (MACA) process, which allows the most effective solution for the requesting department to be established. Where there are …
Under Consideration
#2 —
Recommendation: Previous exercises to test the national response capability, namely Exercises Cygnus and Winter Willow, did not squarely address a disease with the characteristics of covid-19. Nevertheless, some useful lessons were learned and applied, such as the drafting of legislative measures …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#77 —
Recommendation: The initial UK policy was to take a gradual and incremental approach to introducing non-pharmaceutical interventions. A comprehensive lockdown was not ordered until 23 March 2020—two months after SAGE first met to consider the national response to covid- 19.99 This …
Gov response: In future an approach of greater questioning and challenge should characterise the development of policy. Ministers should have the confidence to follow a scientific approach themselves—being prepared to take a more robust approach to questioning …
Under Consideration
#2 —
Recommendation: Previous exercises to test the national response capability, namely Exercises Cygnus and Winter Willow, did not squarely address a disease with the characteristics of covid-19. Nevertheless, some useful lessons were learned and applied, such as the drafting of legislative measures …
Gov response: The government recognises that previous exercises such as Cygnus and Winter Willow have not squarely addressed a disease with the characteristics of COVID-19, and agrees that there are lessons to be learned. For example, the …
Under Consideration
#77 —
Recommendation: The initial UK policy was to take a gradual and incremental approach to introducing non-pharmaceutical interventions. A comprehensive lockdown was not ordered until 23 March 2020—two months after SAGE first met to consider the national response to covid- 19.99 This …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#5 —
Recommendation: Government would have been better prepared for COVID-19 if it had applied learning from previous incidents and exercises. Government was unprepared for a pandemic with widespread asymptomatic transmission, but this was not unprecedented. The early spread of HIV, too, was …
Gov response: The government agrees with the Committee’s recommendation. and the government has done extensive work to model a range of scenarios to better understand the levels of ‘bounce-back’ demand. Modelling estimates that there could be over …
Accepted
#25 —
Recommendation: Given the importance of refining interventions to mitigate both impacts on public health and economic recovery, a review of social distancing measures came quite late. While the scientific approach quite rightly waits for the evidence before making a definitive recommendation, …
Gov response: The Government keeps all non–pharmaceutical interventions and social distancing rules under constant review to ensure the measures remain necessary and proportionate. For example, the Government is legally required to review the Steps regulations at least …
Not Addressed
#1 —
Recommendation: The coronavirus pandemic marks the most significant test of the UK’s emergency advisory and decision-making structures in living memory. As such, it is important that lessons are drawn throughout and applied so that the Government and future Governments may be …
Gov response: The Government is committed to working in a way that is open and transparent about the relevant data and scientific advice used to inform the response to the pandemic. The Government will publish scientific advice …
Under Consideration
#18 —
Recommendation: In March 2020, officials from NHS England & NHS Improvement publicly assured the Health and Social Care Select Committee that these stockpiles meant the country was well placed to manage the COVID19 pandemic. However, the NAO report found that the …
Gov response: 2: PAC conclusion: While government had plans and a stockpile of PPE, this proved inadeq uate for the COVID-19 pandemic. 2: PAC recommendation: The Department must improve its approach to managing and distributing stocks of …
Not Addressed
#17 —
Recommendation: Government had a Pandemic Influenza Preparedness Programme and a stockpile of PPE for managing an influenza pandemic, but not a coronavirus pandemic (such as COVID-19). Public Health England told us this was because the national risk register identified an influenza …
Gov response: 2: PAC conclusion: While government had plans and a stockpile of PPE, this proved inadeq uate for the COVID-19 pandemic. 2: PAC recommendation: The Department must improve its approach to managing and distributing stocks of …
Not Addressed
#2 —
Recommendation: While government had plans and a stockpile of PPE, this proved inadequate for the COVID-19 pandemic. The Department had a strategy for managing an influenza pandemic, which included a stockpile of PPE owned and managed by Public Health England. In …
Gov response: 3. PAC conclusion: HM Revenue & Customs breached its Net Cash Requirement by £726 million.
Under Consideration
#1 —
Recommendation: From the evidence it is clear that there was a disconnect between the assessment of the threat of an infectious disease pandemic (flu or otherwise) and the preparations for such an event occurring. Subsequent government actions (such as the re-drawing …
Gov response: The Government notes the Committee’s recommendation.
Under Consideration
#1 —
Recommendation: The UK has established procedures and structures to prepare for the nation’s major future risks, including a National Risk Register, the Civil Contingencies Secretariat and the Scientific Advisory Group for Emergencies (SAGE). However, the anticipated future risk of pandemic disease …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#80 —
Recommendation: Non-pharmaceutical interventions such as lockdowns, and the testing and isolation of covid cases and their contacts, are tools of temporary application. Once they are lifted, there is nothing to stop transmission resuming. When Sir Patrick Vallance said at a Government …
Gov response: The government, via the World Health Organisation, should make the case for an international standard of reporting COVID-19 deaths and a framework for reporting disease related deaths for future pandemics.
Under Consideration
#75 —
Recommendation: Much of the impact of covid-19 during the first wave was determined by decisions made during the early weeks of the pandemic, between January and late March 2020. The seriousness of the threat to the UK was recognised in January …
Gov response: In the early days of a crisis, scientific advice may be necessarily uncertain: data may be unavailable, knowledge limited and time may be required for analysis to be conducted. In these circumstances it may be …
Under Consideration
#69 —
Recommendation: The Armed Forces should have a more central and standing role in preparing for and responding to emergencies like pandemics, given the depth of capability and experience they have in planning, logistics and rapid mobilisation. The Civil Contingencies Secretariat should …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#1 —
Recommendation: The UK has established procedures and structures to prepare for the nation’s major future risks, including a National Risk Register, the Civil Contingencies Secretariat and the Scientific Advisory Group for Emergencies (SAGE). However, the anticipated future risk of pandemic disease …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#75 —
Recommendation: Much of the impact of covid-19 during the first wave was determined by decisions made during the early weeks of the pandemic, between January and late March 2020. The seriousness of the threat to the UK was recognised in January …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#69 —
Recommendation: The Armed Forces should have a more central and standing role in preparing for and responding to emergencies like pandemics, given the depth of capability and experience they have in planning, logistics and rapid mobilisation. The Civil Contingencies Secretariat should …
Gov response: The government partially accepts this recommendation. The Armed Forces have and continue to play an important role in preparing for and responding to emergencies, providing unique capabilities to support civil authorities. The Civil Contingencies Secretariat …
Under Consideration
#29 —
Recommendation: We found in our report on Government preparedness for the COVID-19 pandemic: lessons for government on risk that government would have been better prepared for COVID-19 if it had applied learning from previous incidents and exercises.52 The NAO reported that, …
Gov response: 1.1 The government agrees with the Committee’s recommendation. 29 Recommendation implemented 1.2 Throughout the COVID-19 pandemic, departments considered the efficacy of policies implemented, and those lessons learned continue to inform contingency planning and are considered …
Not Addressed
#24 —
Recommendation: Throughout the pandemic, the UK has relied on its own bespoke system of science advice and guidance on non-pharmaceutical interventions, while at the same time global-level guidance has been issued regularly by the World Health Organisation (WHO). There have also …
Gov response: The Government keeps all non–pharmaceutical interventions and social distancing rules under constant review to ensure the measures remain necessary and proportionate. For example, the Government is legally required to review the Steps regulations at least …
Not Addressed
#28 —
Recommendation: The NAO reported that the circumstances in which government had to implement the traffic light system had often been a crisis response requiring government to move at pace.49 The Cabinet Office explained that the system was a response to the …
Not Addressed
#27 —
Recommendation: We acknowledge that a large part of the success to date into the development of covid-19 vaccines and therapeutics can be credited to lessons learned from previous outbreaks and efforts made to prepare for future crises. As further promising vaccine …
Not Addressed
#10 —
Recommendation: We welcome the assurances that public health is a priority for the COP26 Unit, while acknowledging the challenges presented by continuing uncertainties. We recommend that the UK Government engages on this issue constructively with the Scottish Government. The Government should …
Gov response: The Government is ensuring that the health of participants and the local community is foremost in our planning for COP26. The excellent joint working between the UK Government, Scottish Government and Scottish Delivery partners is …
Not Addressed
#7 — Serious threat to UK warfighting ability due to Airborne Early Warning capability gap
Recommendation: With only a limited number of (comparatively vulnerable) fixed and mobile land- based radars on UK soil, all of which would be primary targets for our opponents were the current Ukraine conflict to escalate, the capability gap in Airborne Early …
Gov response: The Wedgetail programme replaces the E-3D Sentry Airborne Warning and Control System aircraft, and will offer a step change in capability, providing 5th generation airborne surveillance, command and control that is essential to counter current …
Accepted
#28 — National resilience standards for LRFs are voluntary, with many outdated community risk registers
Recommendation: Local organisations have a critical role in responding to emergencies and building resilience.50 Emergency responders in a local area convene in local resilience forums (LRFs) and the Cabinet Office published a set of national resilience standards for LRFs in 2020. …
Gov response: The Chancellor of the Duchy of Lancaster announced that he would oversee a review of national resilience. A Treasury Minute will be published once this review has concluded. The Cabinet Office will write to the …
Not Addressed
PPO Death in Custody Recommendations (4)
The Governor
The Governor should ensure that all prison staff are made aware of and understand PSI 03/2013 on medical emergency codes so that staff accurately and appropriately communicate the nature of a prisoner’s medical condition.
The Director
The Director should ensure that all staff understand their responsibilities in a medical emergency, including that they radio the appropriate medical emergency code without delay.
The Governor
The Governor should ensure that an ambulance is called promptly if a qualified clinical professional says that one is required.
The Head of Healthcare
The Head of Healthcare should ensure that all emergency response staff attend medical emergency codes immediately.
IOPC Learning Recommendations (3)
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: The leads on emergency services multi-agency working at the National Police Chiefs Council (NPCC), National Fire Chiefs Council (NFCC) and the Association of Ambulance Chief Executives (AACE) monitor services’ compliance with the JOL action note. On …
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: Joint Emergency Service Interoperability Principles (JESIP) issues a ‘Joint Organisational Learning’ (JOL) action note to all emergency services, requiring them to: JESIP is a programme that seeks to continually improve the way the emergency services work …
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: The National Police Air Service (NPAS) develops guidance for emergency services call handlers on NPAS helicopter capabilities, making it clear that NPAS helicopters do not have a rescue capability. This guidance should also: On the night …
NAO Audit Recommendations (5)
The government’s approach to test and trace in England – interim report
b) plan against a range of plausible outcomes to ensure it has flexibility to respond to predictable and unexpected spikes in testing demand. Problems emerged when schools and universities reopened in September, despite a predictable spike in demand. NHST&T also …
Partially accepted
Resilience to animal disease
g ensure their disease outbreak plans are comprehensive and up-to-date, including updating disease-specific plans where required, ensuring plans cover responding to concurrent large exotic disease outbreaks and a scenario where capacity is insufficient, and developing a contingency plan for an …
Accepted
Managing cross-border travel during the COVID-19 pandemic
b) Departments should establish a clear system-level risk management framework to support government decision-making. The framework needs to be responsive to capture the dynamic and complex circumstances of the pandemic; informed by up-to-date data against relevant performance metrics, captured and …
Accepted
Managing cross-border travel during the COVID-19 pandemic
a) Departments should establish who is responsible for capturing and managing the risks for an overall system-based approach to COVID-19 or similar travel measures. Working together, departments should clarify the government?s risk appetite as a basis for any future cross-border …
Accepted
Delivery of employment support schemes in response to the COVID-19 pandemic
k) HM Treasury should ensure it develops robust plans for responding to economic shocks linked to health, environmental or other crises. Plans should be stress-tested to identify improvements and continually refined
Accepted
IMB Recommendations (6)
Ford (2020)
For the second year running the Board comments on your service’s apparent lack of understanding of Category D open prisons. The Prisons National Framework response to COVID-19 including the coloured Levels/Stages diagram and supporting text failed to mention ROTL, even at Levels 1 or 2 where it might be expected. The Board understands that the number one priority was the …
HMPPS
Aylesbury (2020)
Move out of COVID-19 lockdown protocols as swiftly and smoothly as possible, following guidelines as necessary.
Governor / Director
Send (2021)
The Board urges the Ministry of Justice to learn lessons from the last 12 months to develop a strategy for a future pandemic which ensures the humane treatment of prisoners (3.2).
Ministry of Justice
Heathrow and City airports Short Term Holding Facilities (2021)
Border Force should ensure that all its staff are aware that the terminal evacuation protocol requires that C&C are informed without delay to enable them to evacuate the holding rooms.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
Implemented the partially accepted recommendation that a new holding room be set up in Terminal 2 at Edinburgh Airport.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
We repeat our previous recommendation that Prestwick STHF, which remains out of use, should be brought up to basic requirements.
Other