Outdated Operational Guidance
Lack of real-time access for operational staff to up-to-date and succinct guidance, leading to potential inconsistencies or errors in enforcement.
476 items
14 sources
8 inquiries
Source spread
Where this theme appears
Outdated Operational Guidance has been flagged across 14 independent accountability sources:
98 inquiry recs
220 PFD reports
52 committee recs
15 CQC actions
9 ICIBI recs
10 PPO recs
62 IOPC recs
1 NAO rec
2 IMB recs
1 patient safety alert
2 detention investigation recs
1 PHSO decision
2 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (98) — showing 50 strongest matches
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: GO-Science already maintains an expert register for SAGE and is committed to refreshing the register; improving selection processes to broaden participation across disciplines, institutions and backgrounds; and increasing our engagement with experts outside of emergencies. …
Accepted
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-M1.7 — 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-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-M1.3 — 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
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
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-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-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
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
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
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
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
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
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
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-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
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-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-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
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
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-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-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-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-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-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
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
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
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
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
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
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-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
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
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
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
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
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-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-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-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
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-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-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
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
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
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
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
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
PFD Reports (220) — showing 50 strongest matches
Jared William McDowall
Concerns: Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Response (University Hospital Bristol): University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Responded
Isabella Hope Hill
Concerns: Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.
Response (Liverpool Womens NHS): The Trust has enhanced local education for staff on the Neonatal Unit regarding revised guidelines, reviewed and clarified the Service Level Agreement for Radiology to ensure X-rays are performed within …
Responded
Wilhelmina Isobel Newton
Concerns: The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Response (Cumbria County Council): Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it …
Responded
Yousef Shokri-Gharab
Concerns: An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies …
Responded
Scarlett Sinclair
Concerns: The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an unstable condition.
Overdue
Keith Martin
Concerns: Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.
Overdue
Adrian Cowan
Concerns: The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.
Response: Barnet, Enfield and Haringey Mental Health Trust has reviewed and updated the Trust’s resuscitation policy to include additional action to be taken in response to the “deteriorating patient”. They have …
Overdue
Vincent Gibson
Concerns: Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.
Overdue
Thomas Smith
Concerns: Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.
Overdue
Nathan Healer
Concerns: A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is a delay in finalising and implementing updated national guidance for neonatal hypoglycaemia management.
Response (Department of Health): The Department of Health notes the concerns raised regarding the NICE guideline CG63 and its review. They state that draft guidance is due to go out for consultation in September …
Responded
Faye Rippon
Concerns: Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of Abortion Act amendments. Foeticide should be considered before induction at this stage.
Overdue
Clive Turner
Concerns: Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service reviewed the delayed response, implemented a new clinical support desk for early triage of calls, staffed by paramedics and nurses, using the Manchester Triage System. This …
Responded
Caroline Carter Crowther
Concerns: Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.
Overdue
Elouise Winship
Concerns: There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.
Overdue
Elsie Plumb
Concerns: The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
Overdue
Phyllis Kerry
Concerns: There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.
Response (Nottingham University Hospitals NHS Trust): A new guideline has been prepared to improve the management of anticoagulation in patients with intracerebral hemorrhage, clarifying specialty responsibilities. The specialties involved are currently consulting with colleagues to finalize …
Response (Nottingham University Hospitals NHS Trust2f): A new guideline for treating warfarin patients with intracranial hemorrhage has been agreed and will be communicated to medical staff and included in specialty inductions. The guideline group will also …
Responded
Francoise Snape
Concerns: No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.
Overdue
Mohammed Yousaf
Concerns: There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.
Overdue
Lexie Harrison
Concerns: A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.
Response (Cardiff and Vale University Health Board): The UHB acknowledges the coroner's concerns regarding the lack of standardized practices for paediatric endoscopy procedures, but states that they are unable to take the concerns forward themselves and suggest …
Response (The Leeds Teaching Hospitals NHS Trust): The Trust shared the coroner's report with relevant staff and clarified their existing guidelines for managing bleeding oesophageal varices, including resuscitation, antibiotic use, Sengstaken tube placement, and banding procedures. They …
Overdue
Paige Bell
Concerns: Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.
Response (Northumberland Tyne Wear NHS Trust): The Trust believes there was confusion about contradictions in the observation policy. While acknowledging improvements are needed in recording information, they state that information was shared and available to decision-makers.
Response (Department of Health): The Department of Health acknowledges the concerns regarding electronic patient records, national policy on patient engagement and observation, and NICE guidelines for Borderline Personality Disorder. They describe existing systems and …
Responded
Michael Pollard
Concerns: An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, up-to-date system.
Response (University Hospitals of Leicester NHS Trust): University Hospitals of Leicester NHS Trust's Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the …
Responded
David Bladen
Concerns: There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.
Response (National Institute for Health and Care Excellence): NICE acknowledges the coroner's concerns about a lack of national guidance on VTE prophylaxis for patients in lower limb braces. NICE's clinical guideline (CG92) on VTE recommends mechanical VTE prophylaxis …
Responded
Thomas Beaty
Concerns: Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', and the term 'gentle' traction was misleading; furthermore, it's difficult for Trusts to change guidance until the RCOG issues changes/improvements.
Response (Department of Health): The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG.
Response (Pennine Acute Hospitals): The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The …
Overdue
Michael Quinn
Concerns: Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.
Overdue
Dean Joseph
Concerns: Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Response: The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers …
Responded
Glenda Day
Concerns: A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to safe home leave procedures.
Overdue
Stefen Boswell
Concerns: Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.
Response (West Mercia Police): West Mercia Police and Warwickshire Police have harmonised policies and procedures with the Authorised Professional Practice (APP) for police pursuits. All police vehicles entering service are now fitted with an …
Responded
Carl Dickerson
Concerns: Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations for a special aviation category.
Response (CAA): • The CAA has instigated a thorough review of the rules applicable to flights performed under Instrument Flight Rules (IFR) outside controlled airspace through our Safety Review Committee. • This …
Responded
Douglas Kay
Concerns: There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.
Response (DBH Trust): The Trust developed an Upper GI Bleed Transfer Policy for Bassetlaw Hospital after consultation between anaesthetic and medical teams. Staff will be made aware of the policy, and it will …
Responded
Joseph Sarkozi
Concerns: Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.
Response (Avon Fire PFD): Avon Fire & Rescue will include the incident scenario in training packages for operational crews, notify personnel via the "Fire Alert" system, amend the Domestic and Residential Fires risk card, …
Overdue
Wilfred Pearson
Concerns: Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Response (W Pearson): Tameside Hospital NHS Foundation Trust revised the Status Epilepticus Policy twice since Mr. Pearson's admission, including references to recent guidance in the Lancet Medical Journal. They have also provided MCA/DOLS …
Responded
Derrick Twiate
Concerns: Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.
Overdue
Curt Falk
Concerns: A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.
Response (JCVI): Public Health England will submit work on the cost-effectiveness of extending the HPV vaccination programme to adolescent boys to JCVI by early 2017. In November 2015 JCVI advised that a …
Overdue
Christ Morrison
Concerns: Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.
Response (Epsom and St Helier NHS Trust): Epsom and St Helier University Hospitals NHS Trust reviewed and updated the Trust's 2015 Tracheostomy Policy to give clearer sign posting to national guidelines. The updated policy has been submitted …
Overdue
Edward Paddon-Bramley
Concerns: Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.
Response (NSC): The UK NSC commissioned an update review into antenatal screening for GBS in December 2015 and expects to hold a public consultation in the autumn for three months, after which …
Response (Department of Health): The Department of Health notes concerns about differing guidelines for prolonged ruptured membranes (PROM) and GBS screening. They highlight that NICE guidelines represent best practice and that the RCOG provides …
Overdue
Marjorie Booth
Concerns: Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of missing a fracture outweighs radiation exposure risk for elderly patients.
Overdue
Alan Dimbleby
Concerns: Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.
Response (Bateman Engineering Ltd): Bateman Engineering has changed the design of their cabs to include seat restraints, and now fits them on all vehicles before they leave the workshop.
Response (Alan DIMBLEBY): HSE will raise the issue of seat restraints on self-propelled sprayers at the next appropriate meeting for consideration in future revisions of applicable standards and will consider revising guidance to …
Overdue
Mark Seward
Concerns: A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety risks.
Response (SEWARD): The company has reminded staff about the health and safety policy, reviewed the site safety induction, and introduced a new traffic management plan. They have also invested in new health …
Overdue
Helen Patton
Concerns: Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.
Response (Department of Health): The Department of Health acknowledges concerns regarding mini tracheostomy procedures, and includes a joint response from the Faculty of Intensive Care Medicine (FICM) and the Royal College of Anaesthetists (RCOA). …
Response (The Royal College of Anaesthetists): The Faculty of Intensive Care Medicine and Royal College of Anaesthetists reviewed information about a death following a minitracheostomy, but state the provided data is inadequate to answer questions definitively …
Responded
Henry Hicks
Concerns: Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.
Response (Metropolitan Police Service): The Metropolitan Police states that the existing pursuit policy remains unchanged but will be fully explored in the context of a formal disciplinary process for the officers involved, and notes …
Responded
Khazna Khalaf
Concerns: Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.
Overdue
Robert Dearing
Concerns: Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices poses a safety risk.
Overdue
Samantha Hopkins
Concerns: Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Response (South Central Ambulance Services NHS Trust): New labels detailing exclusion categories will be placed on further issues of the trial drug packs. SCAS has committed that by January 2017 that all trial drugs in circulation will …
Response (Warwick Medical School): The University has instructed participating Ambulance Services to issue a reminder to all participating staff, to reiterate the inclusion and exclusion criteria for the trial. Compliance with this instruction shall …
Responded
Denis Cronin
Concerns: Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment design posed a release risk.
Response (Denis Cronin Response2): BSAC is rewriting its core Diver Training Programme to include a skills sheet for instructors to sign off individual skills. BSAC will also produce a guidance document on weightbelt removal …
Response (Denis Cronin): Dulwich BSAC 102 will develop a means of recording partial training completion. They will also seek clarification from BSAC regarding sequencing of lessons and guidance on DSMB use.
Responded
Colin Wellings
Concerns: Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Response (Department for Transport): The Department for Transport acknowledges the concerns, explains current regulations regarding tricycle helmets and licensing, and notes that changes to collision reporting codes and helmet regulations are not planned but …
Responded
Nihad Ousta
Concerns: There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological observations.
Overdue
Barbara Turner
Concerns: The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.
Overdue
Frederick Squires
Concerns: A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.
Response (National Institute for Health and Care Excellence): NICE acknowledges the lack of guidance on when to restart Warfarin after a head injury. They will consider extending the scope of their existing head injury guideline in 2017 to …
Responded
James Fox
Concerns: Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Response (Metropolitan Police Service): The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment …
Responded
Joyce Crompton
Concerns: The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.
Response (Belong): Belong has reminded managers and nurses of policy adherence, requested reassessment of residents' choking risk, updated staff training, and will review policies in a meeting with registered managers. Staff at …
Responded
Committee Recommendations (52) — showing 50 strongest matches
#40 — Commission NICE to develop and disseminate comprehensive guidelines for all reproductive health conditions, monitoring adherence.
Recommendation: The Department of Health and Social Care and NHS England should commission NICE to develop comprehensive guidelines for all reproductive health conditions. Those guidelines should be communicated to GPs and made accessible to patients through the NHS website to allow …
Gov response: We agree that reproductive health is an important area for the development of clinical guidelines. NICE has identified women’s and reproductive health as a priority area for guideline development, and already has an extensive portfolio …
Partially Accepted
#5 — Specify in statutory guidance that boys must be taught female reproductive health conditions
Recommendation: The statutory guidance should specify that boys should be taught about female reproductive health conditions.
Gov response: The government recognises that raising awareness of reproductive ill health is crucial to improving people’s experiences of care and ensuring that no one feels that their pain is dismissed, regardless of ethnicity or socio-cultural situation …
Under Consideration
#33 — Current highway infrastructure Code of Practice contains significant gaps, requiring urgent updates.
Recommendation: The Department told us that Ministers are considering a review of the Code of Practice as it considers there to be value in doing so, even though it will be major task to update the more than 260-page document. The …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: September 2026 6.2 The government agrees that the current guidance that has been provided to local highway authorities through the ‘Code of Practice for …
Accepted
#32 — Department provides outdated guidance for local authorities on road network maintenance.
Recommendation: The Department is responsible for providing guidance to local authorities in England to help them run and maintain their road networks, but has not updated its guidance for several years.70 Such guidance has included good practice proactive maintenance to reduce …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: September 2026 6.2 The government agrees that the current guidance that has been provided to local highway authorities through the ‘Code of Practice for …
Accepted
#6 — Update and regularly revise local road guidance to reflect best practices and new challenges.
Recommendation: The Department has not provided enough support and guidance to local authorities to deal with current and future challenges in maintaining local roads. The Department is responsible for providing local authorities with guidance on the management and maintenance of local …
Gov response: The government agrees with the Committee’s recommendation. Infrastructure should be a reliable source of guidance that remains current. The department has commissioned TRL to work with the sector to develop a structure for the refreshed …
Accepted
#36 — Provide clear guidance for commissioning research coherent with hunger-fighting aspirations and food systems.
Recommendation: The Government needs to ensure that research is coherent with its aspirations to fighting hunger and considers the inter-related factors facing nutrition and food systems. As part of the Zero Hunger delivery framework there should be clear guidance on this …
Gov response: Partially Agree. We agree that research must address the interconnected factors impacting nutrition and food systems in order to effectively fight hunger. That is why, the FCDO has adopted a food systems approach to tackling …
Partially Accepted
#7 — Urge Ministers to issue revised Marine Policy Statement by January 2026 reflecting pressures
Recommendation: We urge Ministers to issue a revised Marine Policy Statement no later than January 2026. The updated statement should reflect the current and evolving pressures on the marine environment, clearly outline the Government’s priorities for marine usage, and set out …
Gov response: Defra recognises the role that the Marine Policy Statement (MPS) plays in setting a high-level context for marine planning and the development of marine plans. The key documents which guide spatial planning decisions are marine …
Not Accepted
#6 — Update the outdated Marine Policy Statement at the earliest opportunity
Recommendation: The current Marine Policy Statement is outdated, not fit for purpose and no longer reflects Government policy or pressures on the marine environment. It therefore must be updated at the earliest opportunity. (Conclusion, Paragraph 33)
Gov response: Defra recognises the role that the Marine Policy Statement (MPS) plays in setting a high-level context for marine planning and the development of marine plans. The key documents which guide spatial planning decisions are marine …
Not Accepted
#13 — Increase long-term public contract opportunities; update procurement strategy with comply-or-explain for UK products.
Recommendation: To ensure that there is sufficient long term demand signalling, we recommend that Government Departments increase the proportion of public contract opportunities in their pipeline that are five to ten years out. . We also recommend that the Government update …
Gov response: 8.1. The Government also recognises that long-term signalling is critical, and the provision of clear, long-term signals to suppliers, for example by targeting at least 10% of the MOD’s equipment procurement budget for novel technologies …
Not Addressed
#9 — Provide clear framework for DBT overseas teams to support priority sector export opportunities.
Recommendation: We recommend that Department for Business and Trade teams based abroad are given a clear framework, which they report to Parliament, for how they can support export opportunities for each of the growth driving sectors, in the most important UK …
Gov response: 5.1. The Industrial Strategy sets out that we will refocus the overseas network on Industrial Strategy growth driving sectors, including by: • Directing overseas export and investment officials and diplomats in major markets to prioritise …
Accepted
#34 — Government's static technology requirements and lack of contract agility hinder digital commercial activity
Recommendation: The NAO found that government will need to adopt wide–ranging changes to how it approaches digital commercial activity, which reflect the changing reality of technology markets. For example, it will need to understand its negotiation levers more fully, understand more …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#22 — Government's digital commercial playbook requires significant enhancement and broader consultation for effectiveness.
Recommendation: The GCF accepted that the playbook needed to be enhanced and improved, and said that in doing so it would involve GDS. It explained that its aim was to ensure that the playbook was “really fit for purpose”, in terms …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#21 — Digital, Data and Technology Playbook lacks detail on assessing large project technical feasibility
Recommendation: The government has published a ‘Digital, data and technology playbook’, which sets out key policies and guidance for how digital projects are assessed, procured and delivered.33 We asked whether this would be the primary tool for driving some of the …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#12 — Centre of Excellence expected to refresh digital playbook and produce sourcing strategy
Recommendation: During our evidence session, the Cabinet Office and DSIT identified a range of other areas that they expected the new Centre of Excellence to contribute to. For example, the GCF recognised that it needed to do “a lot more” to …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: December 2025 2.2 The development of the Digital Commercial Strategy will include an agreed approach to supplier and market engagement, with a particular focus …
Accepted
#7 — Government's technology market approach lags, requiring tailored sourcing strategies.
Recommendation: We therefore asked how government was keeping up with the pace of change in technology markets, and when we could expect a coherent strategy in response. DSIT recognised that there was currently a gap between the market in which it …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#2 — Set out Digital Commercial Centre of Excellence's plans and resource balance for activities.
Recommendation: The Cabinet Office and DSIT have many expectations for the Digital Commercial Centre of Excellence to deliver the large–scale improvements needed to current digital commercial activities, as well as its existing aims. Government’s current digital commercial approaches and practices require …
Gov response: The government agrees with the Committee’s recommendation. to supplier and market engagement, with a particular focus on Small and Medium Enterprise and Voluntary, Community and Social Enterprise suppliers, working in conjunction with industry representative bodies …
Accepted
#73 — Utilise HMS Protector more effectively for Antarctic logistics, enhancing MOD/BAS collaboration.
Recommendation: HMS Protector should be utilised more effectively to support the logistical needs of Antarctic research bases, similar to the role of US military and Coast Guard support for US stations. This could allow the RRS Sir David Attenborough to focus …
Gov response: . The Government notes this recommendation.
Under Consideration
#72 — Conduct comprehensive review of NERC's 'single vessel plus' policy by 2030.
Recommendation: By 2030, the Natural Environment Research Council should conduct a comprehensive review of the “single vessel plus” policy, evaluating its impact on Antarctic and Arctic marine science, particularly regarding the delays to approved research projects. The review should focus on …
Gov response: The Government partially accepts these recommendations. 75. NERC has a well-established framework for reviewing, prioritising and implementing any necessary changes related to infrastructure support to enable excellent marine and polar science delivery. The Cruise Programme …
Partially Accepted
#71 — Prioritise RRS Sir David Attenborough for dedicated research, chartering logistics vessels where possible.
Recommendation: We have heard strong concerns from the Antarctic research community about the Natural Environment Research Council’s (NERC) shift to a “one ship plus” model and the reduction of the research fleet from two vessels to one. This has already led …
Gov response: The Government partially accepts this recommendation. 91. The operating model for the RRS SDA aims to use the increased capacity and capabilities in comparison to the previous vessels (including improved endurance, increase in number of …
Partially Accepted
#14 — Clarify National Policy Statements to permit adjustments to electricity transmission strategic parameters when justified.
Recommendation: The National Policy Statements should clarify that adjustments may be made to the “strategic parameters” for new electricity transmission infrastructure set out in the Centralised Strategic Network Plan where this is justified following detailed design development, community consultations or environmental …
Gov response: The proposed amendments to the NPSs mean that the CSNP will only be endorsed when certain steps have been completed, which include completing public consultation and relevant environmental assessments and publication on NESO’s website. Similarly, …
Partially Accepted
#13 — Review and amend EN-1 guidance endorsing CSNP for clarity and consistent language.
Recommendation: The Government should review and, if necessary, amend the proposed guidance endorsing the CSNP in paragraphs 3.3.78 to 3.3.80 of EN-1, to make the language more consistent, unambiguous, and more in keeping with current understandings of the intended purpose of …
Gov response: We welcome this input and received similar comments in response to the NPS consultation. We have included the following changes as a result: • ‘Indicative routes’ will be maintained in the amendment as it is …
Partially Accepted
#12 — Guidance on Centralised Strategic Network Plan endorsement in EN-1 remains unclear.
Recommendation: We welcome the decision to endorse the Centralised Strategic Network Plan (CSNP) in the National Policy Statements. However, we are concerned that the proposed guidance in paragraphs 3.3.78 to 3.3.80 of EN-1 is not clear enough about what, precisely, it …
Gov response: The CSNP will provide strategic level recommendations for transmission infrastructure based on system need and project demand from the SSEP chosen pathway, ensuring that project level details (such as routing) can be explored and consulted …
Partially Accepted
#11 — Strengthen NPS guidance on grid connection weight and clarify future connection prospects assessment.
Recommendation: The National Policy Statements should give significant weight to the availability of a grid connection, as a paramount consideration in determining where electricity generation projects can be located. However, by the same token, where a project has not yet secured …
Gov response: The overarching energy NPS EN-1 contains guidance on how applicants should manage securing a grid connection for their proposed development and the interaction with their application for development consent. EN-1 Section 4.11 states that the …
Accepted
#9 — Clarify specific family group decision-making model within statutory guidance for consistent practice.
Recommendation: The Department should clarify the specific model of FGDM in statutory guidance to ensure that best practice is followed in all local authorities. (Recommendation, Paragraph 22)
Gov response: In current guidance, the Department does not prescribe a specific model of FGDM; however, local authorities are encouraged to consider the evidence for the Family Group Conference model. It is a local authority’s decision on …
Not Accepted
#22 — Work with industry to prevent UK-US economic alignment creating unintended trade obstacles.
Recommendation: The Government should work closely with industry to ensure that closer UK– US alignment on economic security measures, such as investment screening and export controls, does not create unintended obstacles for legitimate trade and collaboration. It should provide clear guidance …
Gov response: Economic security cooperation on areas outlined in the EPD, including investment screening and export controls, will ensure that the UK and US focus on outcomes reflecting our shared national security interests. We will continue to …
Accepted
#21 — Adopt hybrid BCP/PoD plant inspection model and share biosecurity protocols for inland BCPs.
Recommendation: The Government should adopt the Horticultural Trades Association’s proposal for a hybrid inspection model, combining BCP and PoD approaches. Following a short consultation with industry, the Government should designate specific consignments eligible for PoD inspections. Additionally, APHA should share with …
Gov response: The Place of Destination (PoD) scheme, introduced in January 2021, was explicitly designed as a temporary measure to facilitate plant health checks on high-risk goods inland during the post-EU Exit transition period. This approach was …
Partially Accepted
#6 — Airport expansion plans based on outdated ANPS, inconsistent with current government objectives.
Recommendation: We are concerned that airport expansion plans will have been produced prior to the publication of a new ANPS which ought to be in place to provide the airports with strategic guidance. We are also deeply concerned that, given a …
Gov response: As set out in previous responses, the Government is also reviewing, and updating as necessary, the existing Appraisal of Sustainability and Habitats Regulations Assessment, in line with any amendments made to the ANPS. These assessments …
Under Consideration
#11 — Decent Homes Standard previously outdated and in urgent need of reform
Recommendation: We welcome the Government’s changes to the Decent Homes Standard. The current standard has been out-of-date for some time and is in urgent need of reform, given that it was last updated in 2006. (Conclusion, Paragraph 48)
Gov response: 23. On 28 January 2026 we responded to our consultation on an updated and modernised Decent Homes Standard. The new, modernised DHS is designed to meet modern expectations of housing quality. By setting out in …
No Published Response
#14 — Ambiguity in assessing and enforcing Clause 18 duties for GBR, SoS, and ORR.
Recommendation: It is not clear from the Bill how the Secretary of State, GBR and the ORR will be assessed on how they fulfil their clause 18 duties or how the duties will be enforced should they fall short. There is …
Gov response: The Government partially agrees with this recommendation. The Government is clear that the Passengers’ Council must represent all passengers including disabled passengers. Under current arrangements, the Passengers’ Council Board is comprised of 8 members. Two …
Partially Accepted
#13 — Mandate Secretary of State to publish statutory guidance for GBR on weighing competing duties.
Recommendation: As GBR is accountable to the Secretary of State for fulfilment of its duties, we recommend the Secretary of State issues and publishes statutory guidance on how GBR, at least, should weigh up competing elements of the duties. This will …
Gov response: The Government partially agrees with this recommendation. As the Committee notes, currently franchised Train Operating Companies are not bound by the either the general or specific Public Sector Equality Duty (PSED). To underline this Government’s …
Partially Accepted
#12 — Ensure statutory guidance includes details on how ORR should balance GBR duties.
Recommendation: There are benefits to unified duties but the Bill is insufficiently clear on how they will operate in decision-making, in particular the weighting to be assigned to each factor. The Office of Rail and Road will enforce GBR’s business plan …
Gov response: The Government notes this recommendation. The Government welcomes the Committee’s support for the specific inclusion of the needs of disabled passengers in the passenger interest duty at clause 18, and in the duty on the …
Under Consideration
#7 — Update Committee on progress resolving Carer’s Allowance overpayments due to inaccurate guidance
Recommendation: Inaccurate operational guidance has led the Department to incorrectly assess around 26,000 carers as having been overpaid Carer’s Allowance. The main cause of Carer’s Allowance overpayments is claimants having earnings which exceed the permitted limit. The Independent Review of Carer’s …
Gov response: The government agrees with the Committee’s recommendation. review and has appointed a Senior Responsible Owner to make sure it delivers on these. The department has already increased the weekly Carer’s Allowance (CA) earnings limit by …
Accepted
#32 — United Nations peacekeeping missions require reforms, including technology and regular reviews.
Recommendation: However, we recognise that United Nations peacekeeping missions require reforms to ensure they are fit for purpose. This should include consideration of technological solutions—like the use of drones for monitoring conflict zones—to both support United Nations peacekeeping missions and reduce …
Gov response: Agree. 43. HMG agrees that UN peacekeeping remains an indispensable tool for peace and agrees with the need for UN peacekeeping reform as part of the UN80 process. HMG’s overarching reform objective is for peacekeeping …
Partially Accepted
#5 — Government updating ANPS; Heathrow airport expansion decision linked to new ANPS publication.
Recommendation: The Government has confirmed that it is updating the Airports National Policy Statement (ANPS). We welcome the letter from the then Aviation Minister, Mike Kane MP, to the Committee following his appearance which confirmed that the Heathrow decision would not …
Gov response: As part of the ANPS review, DfT is considering how the Government’s four tests for Heathrow expansion, including for noise, should be set. The review is considering changes in legislation, policy and data since the …
Under Consideration
#9 — Make clear to DCO applicants the burden of evidence required against each criterion.
Recommendation: Guidance must make clear to applicants the burden of evidence required against each criterion. Should a pipeline of DCO applications materialise, this guidance should be regularly updated as lessons are learned, rather than waiting for the next NPS review. (Recommendation, …
Gov response: We agree that the guidance must make clear to applicants the expectations for each criterion in EN-7. We judge that EN-7 provides sufficient information on the expectation of developers when considering each criterion. The information …
Accepted
#32 — Establish a Zero Hunger strategic delivery framework by 2025 with clear guidance for FCDO programming.
Recommendation: We recommend that by the end of 2025 a Zero Hunger strategic delivery framework is created that acknowledges the complex interrelationships between climate, gender, disability, conflict, food security and nutrition. The framework should have clear and practical guidance for civil …
Gov response: Partially Agree. We agree, in principle, that any HMG work towards achieving a world without hunger and malnutrition should be guided by a common approach to ensure a coordinated approach across government departments and effective …
Not Addressed
#24 — Lead a review of transport accessibility legislation, collaborating with disabled people, to update and clarify standards.
Recommendation: The Department for Transport should lead a review of transport accessibility legislation in collaboration with the Office for Equality and Opportunity, and with meaningful involvement and leadership by disabled people, to assess how it could be streamlined, clarified and updated, …
Gov response: 28. The Department accepts the need to look again at the legislative framework for accessibility in transport. The inquiry has highlighted the complex nature of the legislative framework that has grown over the years and …
Not Addressed
#23 — Transport accessibility legislative and regulatory framework is overly complicated and fragmented.
Recommendation: The landscape of legislative and regulatory requirements for transport accessible is overly complicated and fragmented and needs to adapt to changing uses of transport. This prevents both operators and travellers readily understanding rights and obligations, and makes redress harder to …
Gov response: 28. The Department accepts the need to look again at the legislative framework for accessibility in transport. The inquiry has highlighted the complex nature of the legislative framework that has grown over the years and …
Accepted
#2 — Designate a lead department for marine governance and policy coordination by January 2026.
Recommendation: Given the lack of coordination, we recommend that one department must act as the lead authority for marine governance and the coordination of marine policy. This department should be responsible for engaging with other departments and bodies, including The Crown …
Gov response: It is agreed that Government should support the needs of different marine sectors while ensuring the protection of marine nature and sustainable use of the marine environment. The Department for Environment, Food and Rural Affairs …
Partially Accepted
#1 — Blurred responsibilities and poor coordination undermine effective marine governance and accountability.
Recommendation: Whilst balancing economic and environmental demands is important, it is critical to ensure a balance between climate action and nature recovery, particularly in enabling offshore renewable energy developments to meet net zero targets without compromising marine biodiversity. Achieving sustainable marine …
Gov response: It is agreed that Government should support the needs of different marine sectors while ensuring the protection of marine nature and sustainable use of the marine environment. The Department for Environment, Food and Rural Affairs …
Not Addressed
#33 — Government's fragmented cloud buying approach limits potential commercial leverage and benefits
Recommendation: Government has made attempts to co–ordinate in order to gain benefits from its scale. GCF has signed agreements with the major cloud providers which allow them to treat the public sector as a single customer for the purposes of determining …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: December 2025 6.2 The Commercial Operating model is evolving to consider how to facilitate the delivery of the functional standards for commercial and digital …
Accepted
#26 — Digital commercial expertise is unevenly distributed across government departments, lacking universal provision.
Recommendation: We observed that our predecessor Committee saw examples where departments made mistakes in designing and procuring digital programmes, particularly where legacy technology was involved. We were concerned that some larger departments are better served with digital skills than some of …
Gov response: 4.1 The government agrees with the committee’s recommendation. Target implementation dates: first phase by September 2025, second phase by March 2026, final phase to be confirmed. 4.2 Within the GCF there are already 500 individuals …
Accepted
#6 — Design a detailed commercial construct for cross-government digital technology procurement.
Recommendation: Government is underestimating how difficult it will be to consolidate its buying power centrally when procuring digital technology across government, in a way that will give it maximum leverage. Spending over £14 billion annually on digital technology suppliers gives government …
Gov response: The government agrees with the Committee’s recommendation. of the functional standards for commercial and digital and will be adjusted to reflect any proposed changes to the Commercial operating model under the Cabinet Office departmental transformation …
Accepted
#62 — Implement long-term strategy to maximise fieldwork opportunities for Antarctic researchers.
Recommendation: As infrastructure projects near completion, the British Antarctic Survey (BAS) and Natural Environment Research Council (NERC) should implement a long-term strategy to maximise fieldwork opportunities, ensuring fair and efficient access for researchers. This should include improved scheduling, better logistical coordination, …
Gov response: . The Government accepts this recommendation.
Accepted
#54 — Evaluate existing reunification practices and publish national guidance based on local authority good practice.
Recommendation: The Department for Education should evaluate existing reunification practice and publish national guidance on reunification, drawing on the good practice that already exists in many local authorities. (Recommendation, Paragraph 133) Disabled children’s care
Gov response: We have also commissioned Foundations to develop a practice guide for reunification which will set out the strongest available evidence translated into actionable key principles and recommendations for local leaders. This is due to be …
Accepted
#23 — Set clear communication standards for asylum accommodation providers, including minimum notice periods
Recommendation: We recommend that the Home Office sets clear standards for providers to communicate with asylum seekers about their accommodation and support, including minimum notice periods for moving asylum seekers to new accommodation. The department should regularly monitor provider practices to …
Gov response: Section 4.2.2 of the AASC Schedule 2 of the Statement of Requirement sets out the contractual obligation of Home Office service providers to notify asylum seekers of any moves, which is underpinned by a service …
Accepted
#13 — Require the Department to update and publish the RCOG maternity staffing tool.
Recommendation: We urge the Department to update and publish the tool produced by RCOG in time for the rollout of the upcoming refreshed Workforce Plan, so that every maternity unit can use it to plan effectively, ensure appropriate staffing and deliver …
Gov response: NHS England is working in collaboration with the Royal College of Obstetricians and Gynaecologists (RCOG) to support trusts to ensure optimal staffing levels are in place to provide high-quality maternity care services. RCOG provided a …
Partially Accepted
#31 —
Recommendation: The FCDO’s failure to have maintained robust travel advice on the front page of the website for Iran between 2016 and 2018 is a significant error which may have made UK nationals less safe in Iran and likely other countries …
Gov response: 59. FCDO travel advice provides information to help British nationals make informed decisions about foreign travel. Travel Advice remains under constant review to ensure it reflects our latest assessment of risks to British nationals. The …
Not Accepted
#6 — Require UK Government to prepare for legislative divergence on assisted dying in UK jurisdictions.
Recommendation: The UK Government must consider how to respond to another jurisdiction in the UK, or the Crown Dependencies, legislating to allow AD/AS, and how it may impact jurisdictions which do not allow it. Following the recommendation by the Jersey Citizens’ …
Gov response: The criminal law is a devolved matter in Scotland and Northern Ireland. The Crown Dependencies are not part of the UK, but are self-governing dependencies of the Crown, with their own health services, legislatures and …
Accepted
#5 — Issue revised guidance for doctors on providing medical reports for assisted dying abroad.
Recommendation: We also heard about the documentation which has had to be secured as part of the application, including a medical report for the person applying. We note that the General Medical Council’s guidance for Investigation Committees assessing a doctor’s fitness …
Gov response: We do not plan to establish a national strategy for death literacy. However, the Government’s inclusion of palliative and end of life care in wider strategies will continue to drive the conversation and reduce the …
Under Consideration
CQC Inspection Actions (15)
The Croft
Policies and procedures were out of date and did not provide guidance to staff in line with current legislation and best practice guidance.
Should Do
Private Ultrasound Scan
The service must ensure policies are comprehensive and reflect current legislation and best practice guidelines in order to give staff guidance for decision making.
Must Do
The Newcastle Clinic
The service should have a system to ensure all polices, procedure and guidance documents are reviewed, are current and are in date.
Should Do
Personal Security Service
The provider should ensure their policies are reflecting suitable legislation, regulation, and other national guidance relevant to the service.
Should Do
Harley Street Private Practice Limited
The service should ensure all the policies were version controlled and dated.
Should Do
Bradley Street
The servicemustreviewtheirpoliciesforrelevancetotheservicecontextandensurereviewdatesareappropriatelyidentified.
Must Do
Baby Bump Limited
The service should ensure all service policies are relevant for the service being provided.
Should Do
Ashton Lollipop
The service must review their policies for relevance to the service context and ensure review dates are appropriately identified.
Must Do
Acorn Hove
We recommend the provider consider current guidance on PRN protocols and take action to update their practice accordingly.
Should Do
The Croft
Neither the registered provider or registered manager had a good understanding of current guidance and legislation in managing health and social care services.
Should Do
Unit 4 Cornishway Industrial Estate
Review policies and standard operating procedures to determine I they reflect the service delivered and monitor performance against any policies
Should Do
The Withins
The provider should consult current guidance on rehabilitation support models to ensure a clear evidence-based structure is followed.
Should Do
My Homecare Peterborough
We recommend the provider seek professional support in the writing of PRN protocols.
Should Do
Eeze Care London
We recommend the provider consider current guidance on managing shared supported living services for people with a learning disability and autism and review their practice accordingly.
Should Do
Cotton Exchange
Theprovidershouldensureitcontinuestoreviewandupdatetheirpoliciesinlinewithbestpractice.
Should Do
ICIBI Immigration Recommendations (9)
An inspection of Border Force practice and procedures in relation to firearms …
Ensure that all national Border Force firearms policy and guidance documents have a clearly defined owner, are subject to regular time-bound reviews and are readily available to operational frontline staff.
An inspection of General Maritime (October 2024 – February 2025)
Update ‘General Maritime’ guidance in line with the revised definition of GM, roles and responsibilities, and record-keeping requirements, ensuring that it is subject to regular reviews to remain up-to-date.
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 8 Review operational guidance in relation to entry clearance and Temporary Admission and provide a steer (with examples) to Border Force officers at the immigration controls on how to …
An inspection of the Border Force intelligence functions at the Humber ports …
Review the policy, process and guidance for the management and dissemination of intelligence to ensure:clear ownership of new intelligence to remove time consuming deconfliction enquiries and prevent duplication of effortagency …
An inspection of General Maritime (October 2024 – February 2025)
Review Border Force’s working definition of general maritime (GM), ensuring that all Border Force staff, Home Office colleagues, partner agencies and other stakeholders, understand what is included and what is …
An inspection of Border Force’s fast parcels operations (May–July 2023)
Review the Border Force Operating Mandate in order to refresh the direction to BF.
An inspection of General Maritime (October 2024 – February 2025)
Relaunch Operation Tipson, setting a date for completion of the initial mapping of all general maritime locations of no later than 31 December 2026, and tasking the Field Intelligence Officer …
An inspection of General Maritime (October 2024 – February 2025)
Empower the Maritime Director to set the minimum standards required of Border Force regions and commands, and of Home Office Intelligence (in conjunction with the Director HOI), when conducting general …
An inspection of Border Force operations at Stansted Airport
Recommendation 8 Review operational guidance in relation to entry clearance and Temporary Admission and provide a steer (with examples) to Border Force officers at the immigration controls on how to …
PPO Death in Custody Recommendations (10)
The Governor
The Governor should ensure that all managers understand the definition of Special Accommodation and the required protective measures set out in PSO 1700.
The Governor
The Governor should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff are aware of the signs of rigor mortis; and fully understand the circumstances in which they should not start, or continue resuscitation, in line with European Resuscitation Council Guidelines.
NHS England and the Welsh Government
NHS England and the Welsh Government should develop national guidance for establishments to develop local standard operating procedures for healthcare input in the use of force/restraints risk assessments. This guidance should also include roles & responsibilities of healthcare during and …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are aware of PSI 03/2013 and radio a medical emergency code in an emergency situation, including in the event of a fire.
The Operational Security Group Director at HMPPS
The Operational Security Group Director at HMPPS should monitor compliance with policy on the use of restraints during hospital escorts (for inpatient and outpatient appointments), including at HMP Littlehey, and discuss the findings with the Ombudsman.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that Early Release on Compassionate Grounds applications are completed in line with Policy Framework by: • ensuring that prison staff request a report from Probation staff for the application; and • …
The Operational Security Group Director at HMPPS
The Operational Security Group Director at HMPPS should monitor compliance with policy on the use of restraints during hospital escorts (for inpatient and outpatient appointments), including at HMP Oakwood, and discuss the findings with the Ombudsman.
The Director of HMP Parc
The Director should consider carefully and set out what further action he intends to take in the case of omissions in unlock procedures.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at high risk of complications from COVID-19 in line with national guidance. Key actions and decisions should be fully documented in prisoners’ medical and personal records.
IOPC Learning Recommendations (62) — showing 50 strongest matches
Recommendations - Sussex Police, March 2020
The IOPC recommends Sussex Police should review ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)' policy with specific reference to the below; The ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ appears to be …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police reviews its Sudden and Unexpected Deaths Procedure, Unexpected Child Death FIM Guide, and Form F13 Report of Sudden Death (notes of guidance) to ensure they are consistent with one another in respect of …
Recommendations - Sussex Police, November 2019
There was a lengthy delay in resourcing a request for a welfare check that was graded Grade 2 (expected response time 1 hour). During the investigation it became apparent there was no single local policy that provided guidance on how …
Recommendations - Sussex Police, March 2020
The Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts …
Police response to a domestic incident - Essex Police, September 2020
The IOPC recommends that Essex Police should review the quality and effectiveness of its initial and refresher domestic abuse training for frontline officers with specific reference to: In this case, the attending officers requested no Police National Computer or other …
Recommendations - Kent Police, November 2020
The IOPC recommends that Kent Police provides their operational employees with clarity on the different definitions of the term ‘vulnerable.’ There are two strands to this recommendation: This recommendation was made after some of the evidence appeared to suggest Kent …
Recommendations - Northamptonshire Police, March 2021
The IOPC recommends that Northamptonshire Police should take steps to assure itself that appropriate systems are in place to ensure that custody staff adhere to their responsibility, in accordance with Paragraphs 8.8 and 8.10 of PACE Code C, to record …
Recommendation - Sussex Police, April 2021
The IOPC recommends that Sussex Police devise specific guidance on the disposal options to be made available when dealing with low level driving collisions committed by any officer on duty but not answering an emergency. All Roads Policing Investigators and …
Recommendations - Sussex Police, April 2021
The IOPC recommends that Sussex Police should review their policy in relation to the use of a spit guard after incapacitant spray has been used. Any detainee should be regularly reassessed to ensure continued use of a spit guard is …
Recommendations - Sussex Police, April 2021
The IOPC recommends that Sussex Police review their policy in relation to cell extraction to ensure it provides guidance on the continued use of, and the removal of, a spit guard during the technique. The policy should define responsibility for …
Recommendation - South Wales Police, October 2020
The IOPC recommends that South Wales Police (SWP) amends the first aid training provided to front line officers to ensure all officers and staff receive training regarding managing a casualty with a head injury. In the interim, SWP should take …
Recommendation - Merseyside Police, March 2021
The IOPC recommends that Merseyside Police should review and update their body worn video policy so that it better reflects national guidance. This follows an IOPC review where at least three officers were present during an arrest but there is, …
Recommendations - Metropolitan Police Service, March 2021
The IOPC recommend that the Metropolitan Police Service (MPS) draft and implement a new standard operating procedure (SOP), or amend any relevant existing SOP, to provide officers with clear guidance as to roles and responsibilities relating to incident management, outside …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police takes steps to ensure all relevant officers and staff, included but not limited to: Gold, Silver, and Bronze Commanders and Force Incident Managers, receive training on the following policies and how they interact …
Stop and search - Bedfordshire Police, October 2018
The IOPC recommends that Bedfordshire Police bring its local guidance on aftercare provided after the use of PAVA (incapacitant spray) in line with the national Personal Safety Manual (PSM). The PSM provides guidance for officers on the application of water …
Stop and search - Bedfordshire Police, October 2018
The IOPC recommends that Bedfordshire Police work with the members of their stop and search scrutiny panel to co-produce Governance policies and procedures that build in an option to recommend referral to the IOPC as part of their escalation process. …
Stop and search - Bedfordshire Police, October 2018
The IOPC recommends that Bedfordshire Police amend their stop and search record slips to include a question about whether force has been used. The slips should also state where information about the type of force will be recorded. During this …
Recommendation - Metropolitan Police Service, April 2020
The IOPC recommends that the MPS should take any necessary steps to ensure that officers are aware of what actions can be taken when criminal investigations or proceedings end, but the victim still requires safeguarding. Such steps might include producing …
Recommendation - Essex Police, May 2020
The IOPC recommends that Essex Police review its relevant policies and procedures (including the Missing Persons Procedures) to ensure that there is a process for the duty sergeant to be notified when officers have been tasked to undertake actions on …
Recommendations - West Yorkshire Police, June 2020
The IOPC recommends that as a part of the ongoing West Yorkshire Police (WYP) review of its missing from home policy, WYP should stipulate which supervisor has command and control of a missing from home report. That officer should record …
Recommendations - West Yorkshire Police, June 2020
The IOPC recommends that as a part of the ongoing West Yorkshire Police (WYP) review of its missing from home policy, WYP should consider directing that once an officer has taken a missing from home report they should liaise with …
Recommendations - West Yorkshire Police, June 2020
The IOPC recommends that as a part of the ongoing West Yorkshire Police (WYP) review of its missing from home policy, WYP should consider clearly defining which officer has the responsibility of conducting research of information systems (eg. Police National …
Recommendation - Sussex Police, September 2020
The IOPC recommends that Sussex Police should change its policy to state that all non-covert arrest enquiries will have at least one officer wearing a body worn camera in attendance. During the course of this investigation it transpired that plain …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police consider updating force policy to robustly cover checking cells specifically for the purpose of detainee safety. Force policy should be clearly communicated to custody staff with training and oversight to ensure that cell checking …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police consider a review of the suitability and effectiveness of metal detectors used in their custody suites. It should be clarified what types of item the metal detectors currently being used can/cannot identify and ensure …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This could be reinforced by additional …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends the MPS should conduct a review of the staffing levels at the Directorate of Professional Standards (DPS) to satisfy themselves that they are adequate to meet the needs of that department. This report makes repeated reference to …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends that the MPS should consider putting policy in place that outlines the minimum standards required in Death and Serious Injury (DSI), complaint and conduct investigations. This policy should address the following requirements: There was a lack of …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends the MPS should create a role profile for Directorate of Professional Standards (DPS) investigators and DPS IOPC Single Point of Contacts (SPoC), outlining the requirements of the role and the role holder’s key responsibilities. The MPS should …
Recommendations - Metropolitan Police Service, June 2020
The MPS should amend their Death and Serious Injury (DSI) investigation report template to specifically reference the three following questions: The MPS reviews of a Detective Constable's (DC) reports suggested that the template used in Directorate of Professional Standards was …
Recommendations - Metropolitan Police Service, June 2020
The MPS should treat daybooks as controlled stationery across the whole force. Recognising that they contain relevant material to criminal, conduct and Death or Serious Injury investigations the movements and continuity of these books should be audited, and they should …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends that the MPS Should consider providing role specific training to all of its professional standards investigators. It is recommended that this training addresses the following requirements: Another issue raised in this investigation was the lack of role …
Recommendation - Greater Manchester Police, September 2020
The IOPC recommends that the College of Policing amend the custody and detention, detainee care section of the Authorised Professional Practice (APP) to make it clear what they expect officers to do when a detainee cannot be roused in accordance …
Police contact with a woman before her death and a subsequent complaint …
The IOPC recommends that Cleveland Police should implement a formal process for feeding back relevant information from Multi Agency Risk Assessment Conference (MARAC) meetings to staff within the Protecting Vulnerable People (PVP) unit. During the misconduct interviews for two officers …
Recommendation - Metropolitan Police Service, November 2020
The IOPC recommends that the Metropolitan Police Service (MPS) should review the spinal injuries topic within its Emergency Life Support (ELS) training for police officers to ensure that scenarios and examples used do not solely focus on motorcycle accidents and …
Recommendation - Metropolitan Police Service, October 2020
The IOPC recommends that the Metropolitan Police custody policy (Risk Management, section D5) should be amended to include specific reference to the Royal College of Emergency Medicine (RCEM) guidance on the Management of Suspected Internal Drug Traffickers (2020) which advises …
Traffic pursuit prior to man's death - Metropolitan Police Service, December 2020
The IOPC recommends that the Metropolitan Police Service make amendments to policy to more clearly define the training required in order for an officer to be authorised to engage in initial phase pursuits. The investigation identified a lack of clarity …
Recommendation - Metropolitan Police Service, November 2020
The IOPC recommends the Metropolitan Police Service reviews and amends their stop and search policies, procedures and training to include a routine risk assessment of the physical environment in which the individual has been stopped, and that this is considered …
Recommendation - Bedfordshire Police, November 2020
The IOPC recommends that Bedfordshire Police should review and amend their policy and guidance regarding the transportation of vulnerable individuals with single crewed officers. The same policy, guidance, risk assessments and safeguarding considerations for those arrested or formally detained should …
Recommendations - Kent Police, November 2020
The IOPC recommends that Kent Police takes steps to reduce the risks inherent in police officer/staff member interactions with vulnerable members of the community. One suggestion would be for Kent Police to ensure those with Axon body worn video (BWV) …
Recommendation - Derbyshire Constabulary, October 2020
The IOPC recommends that even in the case of lengthy and complex searches Derbyshire Police should ensure that at least one officer will be recording the event using Body Worn Video (BWV) at all times. During the course of the …
Recommendation - Cheshire Constabulary, May 2020
The IOPC recommends that Cheshire Constabulary issue a reminder or guidance to their call handling staff in relation to checking all systems prior to making a THRIVE (Threat, Harm, Risk, Investigation, Vulnerability and Engagement) assessment. Cheshire Constabulary should make it …
Recommendations - South Yorkshire Police, June 2020
The IOPC recommends that South Yorkshire Police confirm additional prompts have been implemented into the Smart computer system. An automated warning prompt on the relevant report generated a reminder at 7.05pm to indicate the dispatch target time of one hour …
Recommendations - South Yorkshire Police, June 2020
The IOPC recommends that South Yorkshire Police review the operating procedures of the Smart computer system, along with any training requirements, to enable practitioners to achieve its maximum benefit. The four members of the control room staff interviewed, supported by …
Recommendations - South Yorkshire Police, June 2020
The IOPC recommends that South Yorkshire Police review its procedures regarding managing outstanding incidents to ensure its systems are robust and adequately overseen by control room and district supervision. The majority of reports are allocated and managed by dispatchers, which …
Recommendations - South Yorkshire Police, June 2020
The IOPC recommends South Yorkshire Police review its management and allocation of priority reports, including consideration of how a priority report is dealt with as soon as possible. The aim of a priority graded report is to ensure a police …
Woman carrying a knife shot by armed officers – Merseyside Police, July …
The IOPC recommends that Merseyside Police should remind their officers and staff that immediately after a firearms incident has occurred, the Post Incident Procedure (PIP) process begins, and during the PIP it is important that the identities of Key Police …
Reported concerns of welfare and subsequent police actions to conduct a missing …
The IOPC recommends the Metropolitan Police Service (MPS) informs all police officers and staff involved in missing person investigations of the updated MPS missing person investigation protocol Local Resolution Team, v2.3 May 2020. As part of an ongoing IOPC investigation …
Recommendation - Northumbria Police, March 2022
The IOPC recommends that Northumbria Police amend their Management Of Serious Or Violent Offenders (MOSOVO) policy to ensure it reflects and complies with College of Policing Authorised Professional Practice (APP). The APP states that staff/officers conducting home risk reviews (HRR) …
Recommendation - Avon and Somerset Constabulary, March 2021
The IOPC recommends that Avon & Somerset Constabulary should put in place a mechanism by which a receipt is provided when firearms are seized in line with the Authorised Professional Practice Major Investigation and Public Protection - Firearms Licensing. A …
National Patient Safety Alerts (1)
Detention Investigations (2)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 37
IND produce a security manual for the detention estate.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 36
the operating standards be completed and rolled out across the estate as soon as possible and to a published timetable.
Immigration Detention
LGO / SPSO Decisions (2)
21-007-140 — West Lindsey District Council
Summary: There is evidence of fault by the Council. The Community Protection Notice served on a neighbour due to anti-social behaviour was not worded in a way that it was enforceable. In addition, when the Council got legal advice on the notice, it did not review or revise it to …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
21-008-290 — Uttlesford District Council
Summary: We found fault with the way the Council handled Mr C’s temporary event notice and the advice it gave about his party. The Council agreed actions to remedy the injustice to Mr C.
LGO (Local Government & …
Environment And Regulation
Upheld
Feb 2022