Outdated Operational Guidance
318 items
2 sources
Lack of real-time access for operational staff to up-to-date and succinct guidance, leading to potential inconsistencies or errors in enforcement.
Cross-Source Insight
Outdated Operational Guidance has been flagged across 2 independent accountability sources:
98 inquiry recs
220 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (98)
BAHA-15 — Unit Holding Area Checklist
Recommendation: JDP 1-10 should include a simple checklist covering both the principles and practicalities of accommodation for unit holding areas.
Gov response: Accepted. A checklist for unit holding area accommodation has been developed and included.
Accepted
Delivered
BAHA-21 — Generic CPErS Handling SOI
Recommendation: Permanent Joint Headquarters (PJHQ) should complete work on a generic theatre-level Standard Operating Instruction (SOI) for CPErS handling. This should stand as the starting template for CPErS handling on future operations.
Gov response: Accepted. A generic theatre-level SOI for CPErS handling has been developed.
Accepted
Delivered
BAHA-22 — Tactical Questioning Policy Clarity
Recommendation: Urgent consideration must be given to amending the tactical questioning policy to make clear what approaches are and are not authorised for use in tactical questioning. In future all tactical questioning and interrogational policies should descend to greater detail on …
Gov response: Accepted. The tactical questioning policy has been amended to provide detailed guidance on authorised approaches.
Accepted
Delivered
BAHA-24 — Harsh Approach Parameters
Recommendation: To the extent that the MoD considers that the harsh approach can still lawfully be used in interrogation: (1) there is a need for very clear guidance to be given within the interrogation policy; (2) the approach should be given …
Gov response: Accepted. Guidance on the harsh approach has been clarified, renamed, and requires Ministerial approval for operational use.
Accepted
Delivered
BAHA-26 — Guidance on Exploiting Pressures
Recommendation: The tactical questioning and interrogation policies should give more detailed guidance on the extent to which tactical questioners and interrogators may seek to exploit self and system induced pressures.
Gov response: Accepted. More detailed guidance on self and system induced pressures has been provided.
Accepted
Delivered
BAHA-29 — Medical Personnel Role
Recommendation: Armed Forces medical personnel can and should be involved in providing advice that a CPErS is not fit for detention or questioning. Alternatively, the medic may validly advise that no specific intervention different from the normal process is required. Medics …
Gov response: Accepted. The role of medical personnel has been clarified to focus on identifying unfitness rather than certifying fitness.
Accepted
Delivered
BAHA-3 — Broaden Stress Position Definition
Recommendation: The definition of stress positions in JDP 1-10 and elsewhere should be broadened so that it is not dependent upon the intention of the person enforcing the position.
Gov response: Accepted. The definition has been broadened to: 'Any physical posture which a captured person is deliberately required to maintain will be a stress position if it becomes painful, extremely uncomfortable or exhausting to maintain.'
Accepted
Delivered
BAHA-30 — CPErS Medical Examination Policy
Recommendation: The medical policy for CPErS should include: (1) CPErS must undergo a medical examination within four hours of capture, unless there are compelling circumstances; (2) CPErS should be examined by a qualified doctor as soon as reasonably practicable; (3) the …
Gov response: Accepted. Medical examination requirements have been updated in line with these recommendations.
Accepted
Delivered
BAHA-31 — Update SOI J3-9 Definitions
Recommendation: The definitions of the prohibited techniques contained in SOI J3-9 should be updated to reflect the recommendations made in respect of JDP 1-10.
Gov response: Accepted. SOI J3-9 has been updated to reflect the revised definitions.
Accepted
Delivered
BAHA-32 — SOI J3-9 Sight Deprivation
Recommendation: SOI J3-9 should reflect the greater emphasis that is given in the latest draft of JDP 1-10 to avoiding in the first place, where practicable, circumstances in which sight deprivation may be necessary. More generally, it should reflect the five …
Gov response: Accepted. SOI J3-9 has been updated to emphasise avoiding sight deprivation where practicable.
Accepted
Delivered
BAHA-33 — Communicating Deprivation Reasons
Recommendation: Where practicable CPErS who are subjected to sight deprivation or hearing deprivation should be told the reason for it. If being deprived of their sight for some or part of a journey by road or air, CPErS should be told …
Gov response: Accepted. Requirements to communicate with CPErS about sensory deprivation have been implemented.
Accepted
Delivered
BAHA-34 — Consistent Sight Deprivation Terminology
Recommendation: Theatre level detention instructions and guidance should be reviewed to ensure that references to the means of permissible sight deprivation are consistent. The clearest wording is likely to be 'sight deprivation by blacked-out goggles'.
Gov response: Accepted. Terminology has been standardised to 'sight deprivation by blacked-out goggles'.
Accepted
Delivered
BAHA-35 — Detention Timescales Consistency
Recommendation: Theatre level detention instructions and guidance should be reviewed to ensure that references to timescales for detention are clear and consistent. Timescales for detention are an important aspect of managing the risk of abuse.
Gov response: Accepted. Detention timescales have been reviewed and made consistent across instructions.
Accepted
Delivered
BAHA-36 — CPErS Documentation
Recommendation: CPErS documents should be as few in number as possible but they require amendment to ensure that those involved in detention are guided more accurately on what to record. Current CPERS documents have no obvious place for soldiers to record …
Gov response: Accepted. CPErS documentation has been amended to include recording of sensory deprivation use.
Accepted
Delivered
BAHA-37 — Occurrence Book Requirement
Recommendation: A suitable occurrence book must be maintained at all times whenever CPErS are being held at a unit or sub-unit holding facility.
Gov response: Accepted. Occurrence book requirements have been mandated for all CPErS holding facilities.
Accepted
Delivered
BAHA-38 — Single Comprehensive CPErS Order
Recommendation: The MoD should continue its recent practice of ensuring that theatre level instructions and procedures for CPErS are contained within a single comprehensive order that is kept up to date and which can be easily handed over to incoming formations …
Gov response: Accepted. The practice of maintaining a single comprehensive CPErS order has been continued and reinforced.
Accepted
Delivered
BAHA-39 — Review Goggles Use in THF
Recommendation: The Provost Marshal (Army) should formally review whether the current practice of using blacked out goggles for all movement of CPErS within Temporary Holding Facilities is strictly necessary and ensure that it is not being used in circumstances that are …
Gov response: Accepted. PM(A) has reviewed the use of blacked-out goggles in THF and updated guidance.
Accepted
Delivered
BAHA-4 — Hooding Guidance
Recommendation: The essence of guidance on hooding should be that it is prohibited at any time for whatever purpose to place a sandbag or other cover over a CPErS' head.
Gov response: Accepted. Guidance updated to make clear that placing any cover over a CPErS' head is prohibited at any time.
Accepted
Delivered
BAHA-42 — Written CPErS Responsibilities
Recommendation: Before any deployed operation, the Commanding Officer must ensure that there is a clear written explanation of unit level responsibilities for CPErS. If responsibilities are changed during an enduring operation this should be recorded.
Gov response: Accepted. Requirements for written CPErS responsibilities have been implemented.
Accepted
Delivered
BAHA-47 — CPErS Training Content
Recommendation: CPErS training should include both theoretical and practical training in what Forces personnel can and should do when handling CPErS. It is important that training is not limited to prohibitions but conveys good practice.
Gov response: Accepted. CPErS training has been expanded to include positive guidance on good practice.
Accepted
Delivered
BAHA-48 — End-to-End CPErS Training
Recommendation: CPErS training should be woven into the full range of military exercises and training. Such training should be 'end to end', not just focused on planning and the actual combat side of the operation, but including what happens after a …
Gov response: Accepted. CPErS handling has been incorporated throughout the exercise and training cycle.
Accepted
Delivered
BAHA-49 — Consistent Training Materials
Recommendation: Training materials across the Services need to be reviewed to ensure that the messages about all aspects of CPErS handling are clear and consistent. The arrangement whereby the PM(A) will act as a coordinator and validator of prisoner handling training …
Gov response: Accepted. Training materials have been reviewed and made consistent across Services.
Accepted
Delivered
BAHA-5 — Noise Prohibition Definition
Recommendation: The definition of the prohibition on subjecting CPErS to noise should be broadened. It should prohibit subjecting CPErS to any unnecessary excessive noise.
Gov response: Accepted. The definition has been broadened to prohibit subjecting CPErS to any unnecessary excessive noise, with guidance on facility design and use of ear defenders.
Accepted
Delivered
BAHA-50 — MATT 7 Presentation Update
Recommendation: The MATT 7 PowerPoint presentation on the five techniques should be amended to ensure that the definitions of the techniques are consistent with amendments to JDP 1-10; that it is clear that the techniques are not only prohibited as aids …
Gov response: Accepted. The MATT 7 presentation has been updated to reflect current definitions and prohibitions.
Accepted
Delivered
BAHA-51 — Prisoner Handling DVD Update
Recommendation: The 2005 prisoner handling DVD should be amended to avoid misleading messages about sight deprivation in the context of interrogation, and the inappropriate presentation of the interrogation facility. 'Bagged and tagged' is an ambiguous phrase which should not be used.
Gov response: Accepted. The prisoner handling DVD has been reviewed and updated.
Accepted
Delivered
BAHA-52 — Restraint Positions Guidance
Recommendation: Greater clarity and guidance should be given in training in relation to the concept of 'restraint positions'. More must be done to give practical guidance to help service personnel distinguish between unlawful stress positions and the legitimate use of force.
Gov response: Accepted. Clearer guidance on distinguishing stress positions from legitimate restraint has been developed.
Accepted
Delivered
BAHA-53 — Positional Asphyxia Training
Recommendation: MATT 7 and mission specific training for CPErS handling should incorporate suitably pitched training on the risks of positional asphyxia/death by struggle against restraint.
Gov response: Accepted. Training on positional asphyxia risks has been incorporated into MATT 7 and mission specific training.
Accepted
Delivered
BAHA-55 — Operational Law Training Currency
Recommendation: Those responsible for designing the mandatory operational law and values and standards training must keep the training relevant and up-to-date both in its content and in the style and means of delivery.
Gov response: Accepted. Processes for keeping operational law training current have been strengthened.
Accepted
Delivered
BAHA-56 — Operational Law Training Quality
Recommendation: Unit commanders should ensure that the annual operational law training is delivered to the highest standards, so as to avoid it becoming stale or routine. Different media should be used to keep the materials fresh and up-to-date.
Gov response: Accepted. Guidance on maintaining high standards in operational law training has been provided.
Accepted
Delivered
BAHA-57 — Remove Shock of Capture Language
Recommendation: Training soldiers to maintain or prolong the shock of capture is apt to be misunderstood and should not feature in general training. Phrases such as 'calm, neutral and professional' and 'firm, fair and efficient' can properly be used as shorthand …
Gov response: Accepted. References to 'shock of capture' have been removed from general training materials.
Accepted
Delivered
BAHA-58 — Moral Courage Training
Recommendation: MATT 6 training should include discussion and role play scenarios relevant to moral courage. Training materials should include reference to occasions when UK troops have breached the Law of Armed Conflict to avoid any risk of complacency about the conduct …
Gov response: Accepted. MATT 6 training has been enhanced to include moral courage scenarios and historical breaches.
Accepted
Delivered
BAHA-60 — Annual Legal Review of TQ Training
Recommendation: The annual legal review of training materials planned by Defence Intelligence and Security Centre (DISC) is a necessary step. It must include a rigorous scrutiny of the detail of the presentations and speaking notes used on the tactical questioning and …
Gov response: Accepted. Annual legal reviews of TQ training materials have been implemented.
Accepted
Delivered
BAHA-62 — DISC Materials Management
Recommendation: DISC should take immediate remedial action to ensure that: (1) old versions of interrogation branch teaching materials are retained but archived separately; (2) interrogation branch teaching materials are always dated; (3) when legal advice or policy changes require changes to …
Gov response: Accepted. DISC has implemented improved version control and archiving for teaching materials.
Accepted
Delivered
BAHA-65 — Remove Conditioning Terminology
Recommendation: 'Conditioning' should cease to be used as an approved Chicksands or HUMINT term. The term is dangerously ambiguous since it can be used to refer to unlawful means of putting pressure on a prisoner as well the intended meaning of …
Gov response: Accepted. The term 'conditioning' has been removed from approved terminology.
Accepted
Delivered
BAHA-66 — Remove Shock of Capture from DISC
Recommendation: DISC should give consideration to avoiding the terminology 'maintain the shock of capture' and 'prolong the shock of capture' even in their own courses. As a minimum, students on the TQ and interrogation courses should be expressly warned of the …
Gov response: Accepted. DISC courses now warn against misuse of 'shock of capture' terminology.
Accepted
Delivered
BAHA-68 — SERE DVD Review
Recommendation: When reviewing the current Survive, Evade, Resist and Extract (SERE) DVD, Defence Survival Training Organisation (DSTO) should take into account the latest developments in tactical questioning and interrogation policy. DSTO should seek to ensure that ambiguity of terms is avoided …
Gov response: Accepted. The SERE DVD has been reviewed and updated to avoid terminology confusion.
Accepted
Delivered
BAHA-8 — Five Techniques Placement in Doctrine
Recommendation: The prohibition on the five techniques should not appear only within the Tactical Questioning and interrogation section of JDP 1-10 since it has a wider application and importance.
Gov response: Accepted. The prohibition now appears in multiple relevant sections of JDP 1-10.
Accepted
Delivered
BAHA-9 — Five Techniques in JTTP
Recommendation: The prohibition on the five techniques should appear in the Joint Tactics, Techniques and Procedures guidance as well as in the main body of JDP 1-10.
Gov response: Accepted. The prohibition has been included in Joint Tactics, Techniques and Procedures guidance.
Accepted
Delivered
10 — Clarify authorisation for Rule 40 and Rule 42 segregation
Recommendation: The Home Office must amend, as a matter of urgency, Detention Services Order 02/2017: Removal from Association (Detention Centre Rule 40) and Temporary Confinement (Detention Centre Rule 42) and, if necessary, the Detention Services Operating Standards Manual for Immigration Service …
Gov response: An interim Detention Services Order has been published clarifying Rule 40 (removal from association) and Rule 42 (temporary confinement) authorisation protocols. A substantive DSO revision is underway examining assurance mechanisms, staff training, and compliance auditing.
Response Unclear
No update 2+ yrs
15 — New comprehensive use of force detention services order
Recommendation: The Home Office must introduce, as a matter of urgency, a new and comprehensive detention services order to address use of force in immigration removal centres. The detention services order must include the following issues: the permissible justifications for the …
Gov response: A new Detention Services Order on use of force is being developed in consultation with experts, alongside an overhaul of assurance processes and a new escalation system.
Accepted in Part
No update 2+ yrs
18 — Update DSO on food and fluid refusal management and reporting
Recommendation: The Home Office must, as a matter of urgency, update Detention Services Order 03/2017: Care and Management of Detained Individuals Refusing Food and/or Fluid, to ensure that it deals with: food and fluid refusal being clearly and directly linked to …
Gov response: An updated Detention Services Order on food and fluid refusal has been published, linking food and fluid refusal to consideration of the Rule 35 process and the Adults at Risk policy.
Accepted in Part
Delivered
20 — Update guidance on fit to fly and fit for detention medical assessments
Recommendation: The Home Office must review and update Detention Services Order 01/2016: The Protection, Use and Sharing of Medical Information Relating to People Detained Under Immigration Powers, to ensure that guidance given to GPs working in the immigration detention estate in …
Gov response: The government acknowledged NHS England's commissioning responsibility. The government stated that fit to fly letters are 'a medico-legal practice' and outside the responsibility of NHS England.
Accepted in Part
No update 2+ yrs
21 — Update mental vulnerability and mental capacity DSO guidance
Recommendation: The Home Office must review and update Detention Services Order 04/2020: Mental Vulnerability and Immigration Detention: Non-Clinical Guidance to set out comprehensive guidance for detention and healthcare staff where there are concerns that a detained person is suffering mental ill …
Gov response: The government stated it is considering policy on detained people with mental ill health as part of wider work on vulnerable adults, scoping requirements with NHS England.
Accepted in Part
In progress
9 — Ensure effective operation and auditing of all Rule 35 limbs
Recommendation: The Home Office must, across the immigration detention estate, assure itself that all three limbs of Rule 35 of the Detention Centre Rules 2001 (reports by a medical practitioner where: (i) it is likely that a detained person's health would …
Gov response: The detention gatekeeper system reviews suitability for detention. The Adults at Risk in immigration detention policy is in place. A review of the AaR policy and Rules 34 and 35 is underway.
Response Unclear
In progress
FENN-84 — Re-draft fire brigade calling instructions for staff in plain English
Recommendation: Instructions to staff as to the calling of the fire brigade shall be re-drafted in plain English. They must contain only relevant matter.
Unknown
FENN-93 — Engage consultants to rewrite rule book and create staff information materials
Recommendation: London Underground shall engage consultants: (i) to rewrite the rule book and its appendices in plain English; (ii) to produce check lists for station supervisory staff and duty cards for members of staff; (iii) to produce relevant extracts from the …
Unknown
FENN-94 — Consult Railway Inspectorate and LFB before issuing safety documents
Recommendation: London Underground shall consult the Railway Inspectorate and the London Fire Brigade before issuing these documents and any future revisions.
Unknown
P1-3 — LFB to review PN633 Appendix 1
Recommendation: The LFB review, and revise as appropriate, Appendix 1 to PN633 to ensure that it fully reflects the principles in GRA 3.2.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
JB-15.12 — Written guidance for covert monitoring posts
Recommendation: There should be clear and unequivocal written guidance for the CMP from the TFC as to the key information and intelligence that is being sought.
Gov response: MPS formally responded on 28 October 2022 (para 29). Recommendation reviewed by National CMP Working Group. Amended Surveillance MoS in draft addressing this under NPCC governance.
Accepted
Delivered
JB-15.15 — SOP for covert monitoring post evidence recording
Recommendation: When a CMP is being used to gather evidence or intelligence, the MPS (and other forces) should consider developing an SOP to ensure that the information is adequately recorded to provide a clear audit trail.
Gov response: MPS formally responded on 28 October 2022 (para 30). MPS has not yet developed SOP pending national D-DaCS system. Reinforcing national Surveillance MoS via internal guidance and training.
Accepted
No update 2+ yrs
MAI-100 — Event healthcare staff trained in first responder interventions
Recommendation: The Department of Health and Social Care and the Care Quality Commission should consider introducing guidelines to ensure that all event healthcare staff who work at events are trained in first responder interventions.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-103 — Guidance on Ambulance Liaison Officer role
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should consider the scope of the role of an Ambulance Liaison Officer and issue guidance to ambulance services in that regard.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-107 — Ensure immediate HART resource deployment
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should develop procedures to ensure that, so far as possible, each ambulance service trust is able to deploy or call upon HART resources immediately in the event …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-110 — Guidance on event first aid equipment
Recommendation: The Department of Health and Social Care should consider issuing guidance on the first aid equipment that event providers should have available on the relevant premises, as well as where that equipment should be stored to ensure that it is …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-115 — Guidance on equipment for warm zone interventions
Recommendation: The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider issuing guidance on how to ensure that specialist paramedics take with them, into a warm zone, …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-117 — Review UK evacuation to hospital model
Recommendation: The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should review the current model for evacuation to hospital operated in the UK by reference to the different …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-129 — Threshold for Ambulance Liaison Officer at events
Recommendation: The Home Office and the Department of Health and Social Care should consider how the threshold for a requirement that an Ambulance Liaison Officer be present at an event is to be identified.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-135 — Action cards for emergency services in Major Incidents
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should oversee the development and implementation of action cards for the police, fire …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-139 — Review and update JESIP Joint Doctrine
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should review and, as necessary, update the Joint Doctrine.
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
Delivered
MAI-140 — Review Major Incident plans for interoperability
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit, individual police services and JESIP should review what changes need to be made to …
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
Delivered
MAI-141 — Nationally agreed format for all emergency plans
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unity, individual police services and JESIP should develop a nationally agreed format for all plans, …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-144 — Mandatory Ambulance Liaison Officer at events
Recommendation: The Home Office should consider how the presence of an Ambulance Liaison Officer in appropriate circumstances may be made mandatory. This may need to be put on a statutory footing.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-145 — Strategic Co-ordinating Group within two hours
Recommendation: The Home Office should consider the introduction of a national standard requiring a meeting of the Strategic Co-ordinating Group to take place no more than two hours after the declaration of a Major Incident where more than one emergency service …
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
Delivered
MAI-15 — Ensure prompt BTP Bronze Commander appointment
Recommendation: British Transport Police should review its procedures to ensure the prompt appointment of a Bronze Commander during a Major 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
Delivered
MAI-158 — Guidance on commander location during incidents
Recommendation: The Home Office, the National Ambulance Resilience Unit, the College of Policing and the Fire Service College should develop guidance as to where commanders should locate during a spontaneous Major Incident. Steps should be taken to ensure that a consistent …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-162 — Define BTP Senior Duty Officer role in Major Incidents
Recommendation: The role of the Senior Duty Officer in a Major Incident should be clearly defined and explained in the British Transport Police Major Incident Manual. This role should have a corresponding action card.
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
Delivered
MAI-166 — Introduce Major Incident Triage Tool
Recommendation: The team led by Philip Cowburn has devised a tool that is designed to replace the existing systems of primary and secondary triage. It is known as the Major Incident Triage Tool. It already has the support of NHS England. …
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
Delivered
MAI-169 — Review Operation Plato guidance
Recommendation: Those organisations should consider what changes need to be made to the Counter Terrorism Policing Headquarters Operation Plato guidance in order to achieve those aims.
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
Delivered
MAI-23 — Guidance on Silver command deployment to scene
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should issue guidance on the circumstances in which a police officer or officers with responsibility for the tactical/silver command of the unarmed officers at the scene or scenes of a Major …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-24 — Review combined vs separate Gold/Silver Control Rooms
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should review the advantages and disadvantages of a combined Silver and Gold Control Room as opposed to separate rooms, and issue guidance for all police services on best practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-27 — Review terrorist attack notification procedures
Recommendation: Counter Terrorism Policing Headquarters should review the procedures by which it is notified of a terrorist attack to ensure that all police services know that this is an early priority.
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
Delivered
MAI-31 — Joint GMFRS/NWFC incident log review procedures
Recommendation: Greater Manchester Fire and Rescue Service and North West Fire Control should conduct a joint review of the circumstances in which it is appropriate for Greater Manchester Fire and Rescue Service personnel to check the North West Fire Control 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
MAI-34 — Review GMFRS information sharing during incidents
Recommendation: Greater Manchester Fire and Rescue Service should review its guidance and policies on how it receives and passes on information during a Major Incident. It is important that, for any update given, it is established when the last time the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-35 — Review GMFRS Incident Commander policy
Recommendation: Greater Manchester Fire and Rescue Service should review the policy by which the Incident Commander takes up the role, in light of the shortcomings I have identified in the policy in operation on 22nd May 2017.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-36 — Regular expert review of GMP Major Incident plans
Recommendation: Greater Manchester Police should ensure that its plans for responding to a Major Incident, including a terrorist incident, are reviewed regularly by those with the appropriate skills and experience to make meaningful improvements to each plan. This must include a …
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
Delivered
MAI-37 — Ensure GMP role cards are accessible
Recommendation: Greater Manchester Police should ensure that its role cards are always immediately accessible to the officers who are to perform those roles
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
Delivered
MAI-39 — Single consolidated GMP Operation Plato plan
Recommendation: Greater Manchester Police should review its Operation Plato plans to ensure that there is only a single plan to which all can work and that this plan gives clear and consistent guidance on how to respond to an Operation Plato …
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
Delivered
MAI-40 — Include GMFRS capabilities in GMP Major Incident Plan
Recommendation: Greater Manchester Police's Major Incident Plan should be reviewed to ensure that it includes clear guidance on the capabilities of Greater Manchester Fire and Rescue Service, including its Specialist Response Team, as well as on the importance of joint working.
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
Delivered
MAI-41 — Include NWAS capabilities in GMP Major Incident Plan
Recommendation: Greater Manchester Police's Major Incident Plan should be reviewed to ensure that it includes clear guidance on the capabilities of North West Ambulance Service, including its Hazardous Area Response Team, Ambulance Intervention Team and Special Operations Response Team, as well …
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
Delivered
MAI-43 — Guidance on covering deceased at mass casualty scenes
Recommendation: Guidance should be provided to event healthcare providers, to emergency service responders other than paramedics and to the public generally about the circumstances in which those who are believed to be dead should be covered. The guidance should make clear …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-45 — Ensure effective explosive detection dog deployment
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, Counter Terrorism Policing Headquarters and the College of Policing should take steps to ensure that all police services have in place effective systems for the prompt deployment of explosives detection …
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
Delivered
MAI-53 — CPS protocol for section 35 prosecution takeover
Recommendation: It is recommended that the Crown Prosecution Service establish a written protocol in relation to its approach to any application from an inquiry Chairman for a section 35 prosecution to be taken over under section 6(2) of the Prosecution 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
Delivered
MAI-59 — Codify prisoner communication restrictions scheme
Recommendation: I recommend that the scheme be codified, and clear policy and guidance be published so that it can be applied consistently across the prison estate.
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
Delivered
MAI-67 — NWAS policy for relieving Operational Commanders
Recommendation: North West Ambulance Service should ensure that it has a policy that sets out the circumstances in which an Operational Commander may be relieved and how that should occur and be communicated to the outgoing Operational Commander and beyond.
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
Delivered
MAI-75 — Operational Commander to gain situational awareness first
Recommendation: North West Ambulance Service should review its Major Incident Response Plan to make clear that the first resource on scene should assume the role of Operational Commander only once they have achieved situational awareness.
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
Delivered
MAI-96 — Force Duty Officer not to handle media enquiries
Recommendation: The College of Policing should issue guidance to all police services to ensure the following, in the event of a Major Incident: a. The Force Duty Officer is not expected to deal with media enquiries. b. The important task 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
Delivered
POH-11 — Apply best offer principle equally in GLOS
Recommendation: The "best offer" principle which will apply in HSSA, as explained in response to Recommendation 10, shall be equally applicable in GLOS.
Gov response: Department for Business and Trade accepts this recommendation. The "best offer" principle applies equally across GLO, HSSA, and HCRS schemes at all panel stages. This has been in effect since 12 August. DBT will retrospectively …
Accepted
Delivered
POH-14 — Post Office to engage in negotiations during HSSA appeal period
Recommendation: During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated …
Gov response: Department for Business and Trade accepts this recommendation. Rather than a 9-month period, DBT has implemented a 3-month notification deadline for claimants to indicate their intent to appeal, with subsequent deadlines for submission of full …
Accepted
Delivered
POH-15 — Set deadline for HSS claims with guidance on late applications
Recommendation: No claims for financial redress under HSS shall be entertained after midnight 27 November 2025.
Gov response: Department for Business and Trade broadly accepts this recommendation. HSS closes to new claims on 31 January 2026. Post Office is sending reminder letters to outstanding claimants. DBT will publish guidance on exceptional cases that …
Accepted in Part
Delivered
POH-16 — Clarify whether HCRS and OCS assessment processes differ
Recommendation: The Department shall make a public announcement in which (a) it clarifies whether there will be any differences in the process for assessing financial redress, between the merged HCRS and OCS, and the process currently operating in OCS and if …
Gov response: Department for Business and Trade accepts this recommendation. DBT confirms that HCRS applies identical principles to the previous OCS scheme, ensuring no disadvantage to overturned conviction claimants. Case management and independent panel processes are in …
Accepted
Delivered
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: Department for Business and Trade acknowledges this recommendation and sees clear advantages in establishing a standing public body for financial redress. However, the government recognises that establishing such an independent redress body requires careful consideration …
Response Unclear
In progress
POH-18 — Devise redress process for affected family members
Recommendation: The Department shall devise a process for providing financial redress to close family members of those most adversely affected by Horizon. Such family members shall qualify for such redress only if they themselves, have suffered serious adverse consequences by reason …
Gov response: Department for Business and Trade accepts this recommendation. Some close family members of postmasters suffered serious adverse consequences because of the Horizon scandal. DBT is committed to establishing a redress scheme for close family members …
Accepted
In progress
POH-19 — Publish restorative justice programme by 31 October 2025
Recommendation: By 31 October 2025, the Department, Fujitsu and the Post Office shall publish, either separately or together, a report outlining any agreed programme of restorative justice and/or any actions taken by that date to produce such a programme. For the …
Gov response: Department for Business and Trade accepts this recommendation. DBT, Post Office, and Fujitsu have jointly embarked on a postmaster-led restorative justice programme facilitated by the Restorative Justice Council. Sessions began on 23 September 2025. A …
Accepted
In progress
COVID-M1.10 — Independent Statutory Resilience Body
Recommendation: The UK government should, in consultation with the devolved administrations, create a statutory independent body for whole-system civil emergency preparedness and resilience. The new body should be given responsibility for: providing independent, strategic advice to the UK government and devolved …
Gov response: Since the pandemic, significant strategic and material changes have been made to the way in which the UK and devolved governments handle crises. Considerable progress has been made against the longer-term programme to build a …
Response Unclear
In progress
COVID-M1.3 — Improved Risk Assessment Approach
Recommendation: The UK government and devolved administrations should work together on developing a new approach to risk assessment that moves away from a reliance on single reasonable worst-case scenarios towards an approach that: assesses a wider range of scenarios representative of …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.6 — Triennial Pandemic Exercises
Recommendation: The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.7 — Publish Exercise Reports and Lessons
Recommendation: For all civil emergency exercises, the governments of the UK, Scotland, Wales and Northern Ireland should each (unless there are reasons of national security for not doing so): publish an exercise report summarising the findings, lessons and recommendations, within three …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M2.3 — UK-wide Expert Register
Recommendation: The Government Office for Science (GO-Science) should develop and maintain a register of experts across the four nations of the UK who would be willing to participate in scientific advisory groups, covering a broad range of potential civil emergencies.
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
PFD Reports (220) — showing 100 most recent
Mark Turner
Concerns: There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in patients being monitored for clozapine.
Pending
Drew Greaves-Pimblett
Concerns: National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Response: NHS England, through liaison with North West Ambulance Service (NWAS), reports that NWAS has reviewed and amended its Medical Priority Dispatch System (MPDS) guidance for call handlers, introducing clearer protocols …
Responded
Izzah Ali
Concerns: The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due to the risk of anaemia.
Overdue
Jamie Funnell
Concerns: An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.
Response: Practice Plus Group has implemented bimonthly dip tests for emergency response bags, delivered comprehensive training, and implemented a new guidance document. They also confirm that the alcohol dependence policy was …
Responded
Mohammed Khan
Concerns: Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during a critical birth.
Responded
Benjamin Arnold
Concerns: Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines for the LISA procedure and newborn cardiac arrest causes.
Responded
Paul Alexander
Concerns: Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.
Responded
Lewis Johnson
Concerns: The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit authorization decisions.
Responded
Jannat Abbker
Concerns: A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.
Responded
Alonzo Wood
Concerns: Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to inconsistent reliance on individual clinical judgment.
Responded
Afolabi Ojerinde
Concerns: Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.
Responded
James Alderman
Concerns: There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants at risk of suffocation.
Responded
Jon-Paul Prigent
Concerns: Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are outdated, posing significant public road safety risks.
Responded
Lisa Gale
Concerns: Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed diagnosis and treatment of conditions like Acute Fatty Liver of Pregnancy.
Responded
Audrey Lambert
Concerns: There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.
Responded
Sebastian ‘Benji’ Oliver
Concerns: Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from treatment.
Responded
Shirley Hughes
Concerns: The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns that lives are being put at risk by outdated prioritization.
Responded
Michael Crane
Concerns: Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety in critical situations.
Responded
Chad Allford
Concerns: Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of life-threatening choking risks.
Responded
Patricia Lines
Concerns: Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on 20-year-old evidence.
Responded
Brian Beer
Concerns: NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.
Responded
Theo Bradley
Concerns: A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.
Responded
Tony Williams
Concerns: HSE guidance and support materials lack clear images and instructions for drivers on safely loading and unloading overhanging bales on slopes, particularly concerning widthways loading and centre of gravity risks.
Responded
George Dillon
Concerns: Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to life.
Responded
Glenn Jacques and Ben Whiteman and Callum Clark
Concerns: The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, despite previous categorisation suggesting otherwise.
Overdue
Jessica de Souza
Concerns: Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.
Responded
Phephisa Mabuza
Concerns: The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained an incorrectly coded operational policy.
Responded
Peter Dolan
Concerns: The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the risk of fire fatalities from smoke inhalation and burns.
Responded
Alan Kinsbury
Concerns: Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an inappropriate surgical technique.
Responded
Ruth Eggleton
Concerns: The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.
Responded
Arlo Lambert
Concerns: The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.
Responded
Raymond Watkins
Concerns: District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.
Responded
Thomas Gibson
Concerns: The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between specialisms. There's no clear guidance for clinicians or senior review of incongruous test results.
Overdue
Linda McLaughlin
Concerns: Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear guidance on discontinuing long-term medication for patients in remission.
Responded
Louise Jones
Concerns: The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction risk and guidance on co-prescribing opioids with benzodiazepines.
Responded
Tcherno Bari
Concerns: Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding procedures, and ineffective challenge processes between mental health services and police.
Responded
Donna Smith
Concerns: A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.
Responded
Ashley Crews
Concerns: The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety concern.
Overdue
Michael Briggs
Concerns: Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk of infective endocarditis, leading to inconsistency and potential patient harm.
Responded
Terence Sullivan
Concerns: Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding single anticoagulant use.
Responded
Richard Collins
Concerns: Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by the absence of a local policy for assessing driving ability.
Responded
Stanley Cummins
Concerns: Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.
Responded
Severine Kelly
Concerns: Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.
Responded
Blanche Knowles
Concerns: Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' for burn injuries.
Overdue
Kazarie Dwaah-Lyder
Concerns: A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding the need for endoscopy after negative initial imaging.
Responded
O’Shea Dover
Concerns: National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics unit, as per London Ambulance Service practice.
Responded
Dorota Kuklinska
Concerns: Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, as clinicians were unaware of existing protocols.
Responded
Nuel-Junior Dzernjo
Concerns: A lack of clear guidance for prescribing intravenous Acyclovir, instead of ineffective oral medication, potentially led to incorrect treatment and preventable death for the patient.
Responded
Claire Briggs
Concerns: A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.
Responded
Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein
Concerns: A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.
Responded
Katherine Flynn
Concerns: A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops draining but oscillates poses a significant patient safety risk.
Overdue
Maxwell Frame
Concerns: The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy is needed to ensure patient safety.
Responded
Bavaniammah Theiventhiran
Concerns: The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of early death due to delayed intervention.
Overdue
Alfie Mains-Forster
Concerns: The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering effective assessment. A critical updated risk chart (NEWTT2) remains unimplemented despite being overdue.
Responded
Andrew Nichols
Concerns: There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to community care, leading to potential gaps where high-risk patients' needs are not met.
Responded
Mark Bennett
Concerns: Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport for thrombolysis, placing patients at risk.
Responded
Kimberley Sampson and Samantha Mulcahy
Concerns: Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically for Herpes Simplex, put patients at risk.
Responded
Marcel Wochna
Concerns: Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety protocols.
Responded
Isabela Suciu
Concerns: Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
Overdue
Lamont Roper
Concerns: Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and capacity.
Responded
Talia Phillips
Concerns: Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically high levels and warranting review.
Responded
Miss C
Concerns: The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
Overdue
Jonathan Mann and Margaret Costa
Concerns: Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a pilot in distress.
Overdue
Lawson Bond
Concerns: Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies being sold to the public.
Responded
Phoenix Chapman
Concerns: A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective care.
Responded
Gordon Renfrew
Concerns: Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.
Responded
Peter Walker
Concerns: The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to fly.
Responded
Andrew Shambrook
Concerns: The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Responded
Emilia Watson
Concerns: Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing exposure to home birth practice. This raises concerns about maintaining competency in all areas of midwifery practice.
Overdue
Benedict Peters
Concerns: A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.
Responded
Rebekah Mills
Concerns: Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent approaches and failure to recognize fatal risks.
Overdue
Julie Hancock
Concerns: Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about wider patient safety.
Responded
Rachael Walker
Concerns: The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.
Responded
Allah Ismail
Concerns: Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better use of audit tools by NHS Trusts.
Responded
Andrew Brown
Concerns: The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous guidelines on the "silent approach" and use of warning equipment.
Responded
Beryl Holt
Concerns: Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely recognition and treatment.
Responded
Glenn Barton
Concerns: NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other naturally occurring conditions affecting blood clotting, leading to missed diagnostic opportunities.
Responded
Roy Draper
Concerns: There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.
Responded
Muhammad Hassan
Concerns: A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks premature discharge and insufficient information for families on signs of concern.
Overdue
Thomas Hoskin
Concerns: There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.
Overdue
Chloe Lumb
Concerns: The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic steps.
Overdue
Sarah Gilbert-Jones
Concerns: Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.
Responded
Coco Bradford
Concerns: Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.
Responded
Frances Thomas
Concerns: Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, and insufficient scrutiny of age-inappropriate online content in schools.
Responded
Neil Stewart
Concerns: There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined responsibilities for guests.
Overdue
Victoria Harrild-Jones
Concerns: Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.
Responded
Mollie Dimmock
Concerns: NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.
Responded
Rhian Rose
Concerns: There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack of specific guidance for managing infection risks associated with a retained deceased foetus following feticide.
Responded
Leon Briggs
Concerns: The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Responded
Richard Boateng
Concerns: Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.
Responded
Maureen Johnson
Concerns: A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.
Responded
Mark Holden
Concerns: A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.
Overdue
Cherry Dunn
Concerns: National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across trusts.
Overdue
Maurice Leech
Concerns: Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and incomplete information. There is no specific NICE guidance for elderly femur fracture management.
Responded
Adam Forrester
Concerns: A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address checking bins for persons, creating a risk for vulnerable individuals.
Responded
Cpl Ryan Lovatt
Concerns: The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Responded
Levi Petitt
Concerns: Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There is a need for improved training on mental welfare procedures.
Responded
David Ormesher
Concerns: Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
Responded
Nicholas Rousseau
Concerns: Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack of standardized care.
Responded
Sheldon Farnell
Concerns: Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Responded