Patient dignity and privacy

Failure to ensure suitable arrangements are in place to consider and respect the dignity, privacy, and independence of people using care services.

697 items 12 sources 8 inquiries

Strongest matches Browse by source

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Source spread

Where this theme appears

Patient dignity and privacy has been flagged across 12 independent accountability sources:

71 inquiry recs 14 PFD reports 20 committee recs 64 CQC actions 3 PPO recs 1 IMB report 88 IMB recs 2 Article 2 learning points 18 detention investigation recs 147 PHSO decisions 268 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 (71) — showing 50 strongest matches

P2-56 — Unlicensed body stores follow same standards

Recommendation: Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers of licensed mortuaries.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-51 — Local authority biennial audits and peer review

Recommendation: The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal committee regardless of the level of assurance. Local authorities must arrange a peer review of the mortuary service …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-50 — Local authority mortuary as regulated service

Recommendation: The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory committee, with regular reporting. Key performance indicators must be identified …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-49 — Local authority DI management and oversight review

Recommendation: There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the mortuary, level of influence within the local authority, and attendance …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-48 — Local authority annual SOP and HTA audits

Recommendation: There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, with a clear record of authorisation by the Designated Individual, head of service or equivalent. Audits of staff …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-47 — Local authority security breach investigation

Recommendation: There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority as a minimum. Serious security breaches must also be reported …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-45 — Local authority single security SOP

Recommendation: All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security Standard Operating Procedure.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-44 — Local authority incident response SOPs

Recommendation: Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-43 — Local authority CCTV installation

Recommendation: CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges containing deceased people, including where these are accessible from within the post-mortem room. Local authorities must put appropriate …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-42 — Lock fridges and freezers at all times

Recommendation: Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-41 — No reliance on keys/keypads alone

Recommendation: There must be no reliance on keys and keypad codes alone to secure access to the mortuary.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-40 — Local authority strategic security review

Recommendation: Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should include a detailed risk assessment of the potential breaches of security that could occur. The review should include …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-39 — Local authority security audits

Recommendation: Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, including the post-mortem room. Access data must be reconciled against CCTV footage. Audits must be reported to the …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-38 — Local authority lone working review

Recommendation: Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration of activities involving direct handling of the deceased, alongside mitigations that can be put in place to safeguard …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-37 — Local authority visitor supervision

Recommendation: Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must be limited to specific areas required for the purposes of their work or visit. They must be supervised …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-36 — Local authority individualised access controls

Recommendation: Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary and restrict access to specific areas of the mortuary, such as the post-mortem room. There should be a …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-35 — Local authority mortuary access review

Recommendation: There should be a process to routinely review who is permitted to access the mortuary unsupervised.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-33 — Ambulance photography policies

Recommendation: Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may be required, and ensure that ambulance staff are aware of these and comply with them.

Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …

Accepted In progress

P2-32 — Ambulance policies on deceased security and dignity

Recommendation: NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered and/or secured. NHS England should monitor that such policies are in place.

Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …

Accepted In progress

P2-31 — Ambulance policy on crew position with deceased

Recommendation: Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of deceased patients, as well as training requirements.

Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …

Accepted In progress

P2-27 — Hospice security and access controls

Recommendation: Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; have Standard Operating Procedures regarding the care of deceased people, including security of and access to the areas …

Gov response: The Department of Health and Social Care has worked with Hospice UK to ask its clinical leaders group network to urgently review their clinical practices against the recommendations. Hospice UK has already updated its Care …

Accepted In progress

P2-24 — Anatomical education security and dignity policies

Recommendation: All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the security and dignity of donors. These should include: security and access policies and the auditing of security and …

Gov response: This recommendation is under consideration.

Response Unclear In progress

P2-23 — Independent sector accompanied access to deceased

Recommendation: Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased patient do so, even if they are staff members, and that they are always accompanied.

Gov response: The Department of Health and Social Care has met with the Independent Healthcare Provider Network (IHPN), who engaged with its members in September 2025. IHPN members have confirmed they have taken action on the report, …

Accepted In progress

P2-22 — Independent sector SOPs for deceased patients

Recommendation: Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity of any patients that die under their care. Wherever possible, deceased patients' rooms should be kept locked. Providers …

Gov response: The Department of Health and Social Care has met with the Independent Healthcare Provider Network (IHPN), who engaged with its members in September 2025. IHPN members have confirmed they have taken action on the report, …

Accepted In progress

P2-21 — NHS England incorporate deceased in safeguarding framework

Recommendation: NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-20 — Chief Nurse responsibility for deceased safeguarding

Recommendation: The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-5 — Operational barriers including device restrictions

Recommendation: All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. An example of this would be implementation of a rule that prevents electronic devices such as phones or …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-4 — End shared swipe cards

Recommendation: The practice of using shared electronic swipe cards for specific staff groups should cease immediately.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-3 — Audit access data for deceased storage

Recommendation: All NHS trusts should routinely audit the access data of all facilities used to store deceased people.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-2 — CCTV in all NHS mortuaries

Recommendation: All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the doors of body fridges, while maintaining the security and dignity of deceased people by implementing the appropriate safeguards. …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P1-17 — Deceased treated with same dignity as patients

Recommendation: Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does its other patients.

Gov response: Implemented. The Trust has embedded this principle in policy and practice. The deceased are now afforded the same safeguarding and dignity considerations as living patients. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial …

P1-9 — CCTV in mortuary including post-mortem room

Recommendation: Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.

Gov response: Implemented. Full CCTV coverage has been installed throughout the mortuary including the post-mortem room, with appropriate safeguards for dignity. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)

AS-7 — Strip-Search Safeguards

Al-Sweady Inquiry

Recommendation: Appropriate measures should be taken to ensure that minimum safeguards are in place where a detainee is to be strip-searched. These include informing a detainee as to the necessity for the strip-search and requesting his/her co-operation. Those conducting a strip-search …

Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …

BRIS-102 — Ensure patients are informed about innovative procedures and clinician experience

Bristol Heart Inquiry

Recommendation: Patients are always entitled to know the extent to which a procedure which they are about to undergo is innovative or experimental. They are also entitled to be informed about the experience of the clinician who is to carry out …

BRIS-16 — Empower patients to decline information, requiring skilled healthcare professional communication

Bristol Heart Inquiry

Recommendation: Patients should be given the sense of freedom to indicate when they do not want any (or more) information: this requires skill and understanding from healthcare professionals.

BRIS-15 — Inform patients they can have a chosen person present when receiving information

Bristol Heart Inquiry

Recommendation: Patients should be told that they may have another person of their choosing present when receiving information about a diagnosis or a procedure.

BRIS-13 — Provide patients with pre-procedure explanation and post-procedure review opportunity.

Bristol Heart Inquiry

Recommendation: Before embarking on any procedure, patients should be given an explanation of what is going to happen and, after the procedure, should have the opportunity to review what has happened.

P2-55 — Unlicensed body stores prepared for HTA compliance

Recommendation: Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, in the event that a Human Tissue Authority licence is required to enable activities outside Human Tissue Authority …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-54 — Local authority contingent body storage plans

Recommendation: Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-53 — Local authority report implementation to committee

Recommendation: The implementation of these recommendations must be reported to the relevant statutory committee.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-52 — Share mortuary reports with coroner service

Recommendation: All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to see these reports). Local authorities that are not the lead …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-46 — Local authority funding for security expedited

Recommendation: There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited and considered at the highest levels within the local authority.

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P2-34 — Recommendations apply to independent ambulances

Recommendation: The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also be applied to independent ambulance services, including private ambulances.

Gov response: The Association of Ambulance Chief Executives (AACE) has made the Independent Ambulance Association (IAA) aware of the Inquiry recommendations. Where ambulance services have contractual agreements with independent ambulance services, those commissioned services must comply with …

Accepted In progress

P2-30 — Ambulance data on conveying deceased

Recommendation: Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to NHS England, and monitored to assess risk.

Gov response: NHS England has confirmed that relevant data lines are in the information standard with the first routine collection expected to be rolled out in 2026/27.

Accepted In progress

P2-25 — Postgraduate training governance clarity

Recommendation: Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue …

Gov response: This recommendation is under consideration.

Response Unclear

P2-1 — NHS trusts commission specialist security review

Recommendation: All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased people, which should include a detailed risk assessment of the potential breaches of security that could occur. The …

Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.

Accepted in Part In progress

P1-2 — No deceased left out of fridges overnight

Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and that the practice of leaving deceased people out of mortuary fridges overnight, or while maintenance is undertaken, does …

Gov response: Implemented. The Trust has confirmed compliance with this requirement. Standard Operating Procedures updated to ensure deceased persons are not left out of fridges unnecessarily. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement …

COVID-M3.2 — Visiting Restrictions Guidance

COVID-19 Inquiry

Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals in the event of a future pandemic. The guidance should identify the circumstances in which visiting restrictions should …

Gov response: No formal response published by this government.

BRIS-12 — Provide patients with information enabling active participation in their care decisions.

Bristol Heart Inquiry

Recommendation: Patients must be given such information as enables them to participate in their care.

BRIS-11 — NHS employers must ensure staff allow patients time for questions

Bristol Heart Inquiry

Recommendation: Patients should always be given the opportunity and time to ask questions about what they are told, to seek clarification and to ask for more information. It must be the responsibility of employers in the NHS to ensure that the …

PFD Reports (14)

Anthony Brian Flynn

14 Nov 2013 · Manchester West

Concerns: Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.

Response (Sodexo): Sodexo is planning Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch awareness days and a training programme for prison officers who conduct escorts, particularly during hospital visits. …

16 Jun 2014 · Cornwall

Concerns: Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.

12 Sep 2014 · Isle of Wight

Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.

01 Nov 2018 · Milton Keynes

Concerns: The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.

Response (Milton Keynes Clinical Commissioning Group): CNWL Mental Health Trust has informed the CCG that they are commissioning a study to assess the feasibility of creating a new inpatient campus in Milton Keynes, bringing together acute …

05 Apr 2019 · Surrey

Concerns: A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.

07 Jan 2020 · County Durham and Darlington

Concerns: Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.

Response (County Durham and Darlington NHS): Following review, physiotherapists now record changes in mobility or interventions in the Nervecentre system to ensure all staff are aware, in addition to maintaining detailed paper records. A buffer stock …

30 Sep 2020 · Stoke-on-Trent & North Staffordshire Coroner’s Court

Concerns: Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack of escalation or specialist involvement.

Response (Midlands Partnership NHS Foundation Trust): The Trust has identified actions to improve documentation related to pressure areas, including additional training and audits. They will also update the patient care plan template to incorporate the pain …

Robert Walaszkowski

27 Sep 2021 · East London

Concerns: A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.

George Griffiths

28 Jun 2023 · Herefordshire

Concerns: A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.

Response (Wye Valley NHS Trust): The Trust has introduced a senior nurse care review in the ED, developed and piloted a local competency package for pressure area care (starting with the Frailty service), refreshed Tissue …

18 Jul 2023 · Essex

Concerns: A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.

Response (Mid and South Essex NHS Foundation Trust 1): The Trust has updated its action plan and completed several actions to improve personal care, record keeping, and investigation processes including improved management oversight, audits, training, and an updated safeguarding …

22 Feb 2024 · Norfolk

Concerns: There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.

Response (The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust): The hospital trust has implemented daily ward visits by a matron or senior nurse until 21.30 every day and during 08.00-16.30 on weekends and bank holidays to ensure standards are …

04 Oct 2024 · Lancashire and Blackburn with Darwen

Concerns: In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.

Response (Lancashire Teaching Hospitals NHS Trust): Lancashire Teaching Hospitals NHS Trust has formulated an action plan to address the coroner's concerns and will share updates on its progress. The Trust met with the deceased's sister to …

15 Oct 2024 · West Sussex, Brighton and Hove

Concerns: The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.

Response (NHS England): NHS England states that delivery of care in temporary escalation spaces is not acceptable. Regional colleagues are visiting Emergency Departments to understand how and why patients are selected to reside …

Response (University Hospitals Sussex NHS Foundation Trust): The Trust has implemented several initiatives including employing an Operational Flow Improvement Manager, commencing a Continuous Flow model, and opening a Surgical Assessment Unit to improve patient flow and reduce …

Response (Department of Health and Social Care): The DHSC acknowledges concerns about emergency department capacity and corridor care, referencing NHS England's planned actions and the government's commitment to improving urgent and emergency care performance, including increasing bed …

16 Apr 2025 · Birmingham and Solihull

Concerns: A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.

Response (University Hospitals Birmingham NHS Foundation Trust): University Hospitals Birmingham NHS Foundation Trust has implemented several changes, including daily safety huddles, nurse-in-charge safety checks, and senior sister spot checks. They have also improved the Radar system for …

Committee Recommendations (20)

#24 — Cease using 'benign' and reprioritise chronic reproductive conditions like endometriosis for surgical treatment

Women and Equalities Committee

Recommendation: NHS England should cease to use the term benign in relation to reproductive ill health. The NHS should work with stakeholders to develop a way to describe these conditions that more accurately reflects the serious impact they can have on …

Gov response: We recognise the importance and value of primary healthcare professionals undertaking training in women’s reproductive health conditions. NHS England does not currently plan to collect data on training hours for primary care practitioners due to: …

#23 — Benign gynaecology' terminology downplays reproductive health conditions, risking treatment de-prioritisation

Women and Equalities Committee

Recommendation: The use of terminology such as ‘benign gynaecology’ downplays the impact of reproductive health conditions and risks de-prioritising them for treatment that could significantly improve patients’ health and lives.

Gov response: Primary care is often the first point of contact for women seeking help with their reproductive health and so it’s vital that GPs are well supported to care for reproductive health conditions. Doctors must regularly …

Under Consideration

#22 — Implement policies ensuring separate spaces for reproductive health and obstetrics patients during investigations/treatment

Women and Equalities Committee

Recommendation: NHS England should implement policies to ensure there are separate spaces for patients undergoing investigations or treatment for reproductive health conditions and obstetrics patients. (Paragraph 91) Waiting lists

Gov response: Polycystic ovary syndrome ( PCOS ) is a complex syndrome characterised by: multiple follicles in the ovary menstrual irregularity high testosterone levels Diagnosis is typically made using a combination of: medical history blood tests ultrasound …

Under Consideration

#17 — Enforce informed consent and halt painful gynaecological procedures lacking adequate pain relief.

Women and Equalities Committee

Recommendation: The NHS must do more to monitor and enforce protocols governing procedures such hysteroscopy, IUD fitting and cervical screening and ensure that they are underpinned by informed consent and are trauma-informed. A risk assessment that allows a patient to make …

Gov response: We agree with the importance of robust data collection that supports analysis to help identify where and what interventions are most appropriate. NHS England’s plan on reforming elective care for patients (linked in ‘Introduction’ above) …

#16 — NHS fails patients during routine reproductive procedures, neglecting duty of care and pain management.

Women and Equalities Committee

Recommendation: The NHS is failing many patients who undergo routine reproductive healthcare procedures such as hysteroscopy, IUD fitting and cervical screening. In too many cases, we find that a duty of care from gynaecologists and other medical practitioners is absent. Women …

Gov response: Cutting waiting lists, including for gynaecology, is an important part of our health mission to build an NHS fit for the future and a top priority for this government. NHS England’s plan on reforming elective …

Under Consideration

#14 — Healthcare practitioners insufficiently understand reproductive health treatment options and their impact on patients.

Women and Equalities Committee

Recommendation: Healthcare practitioners lack sufficient understanding of the range and suitability of treatment options available to treat reproductive health conditions. Too often conditions are viewed through the prism of fertility which, while a necessary consideration, should not be the only factor …

Gov response: We sympathise with anyone suffering with infertility. We acknowledge the report’s finding that hospital waiting areas and wards that bring together patients with reproductive health conditions and women who are pregnant, or have recently given …

Under Consideration

#10 — Medical misogyny and racism lead to dismissed pain in women's reproductive healthcare.

Women and Equalities Committee

Recommendation: There is a clear lack of awareness and understanding of women’s reproductive health conditions among primary healthcare practitioners, particularly when those conditions occur in young women and girls. Women are finding their symptoms normalised and their pain dismissed, with an …

Gov response: We agree with the importance of understanding and improving women’s experiences of procedures and ensuring women’s pain is not dismissed. We are working with NHS England and the Women’s Health Ambassador on how we take …

#46 — Sick leave inadequate for miscarriage support, lacking confidentiality, dignity, and sufficient pay

Women and Equalities Committee

Recommendation: conclusion Sick leave is an inappropriate and inadequate form of employer support in the aftermath of a miscarriage or pregnancy loss. It does not afford women adequate confidentiality or dignity and puts them at high risk of employment discrimination. The …

Gov response: First Special Report of Session 2024–25 HC 803 Women and Equalities Committee The Women and Equalities Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Government Equalities …

Under Consideration

#70 — Strictly limit handcuff use for child transport and ensure provider accountability with Ofsted.

Education Committee

Recommendation: The Department for Education must act to strictly limit the use of handcuffs to those cases where it is otherwise unavoidable or necessary for the child’s own safety, and work with Ofsted to ensure that local authorities and transport providers …

Gov response: The safeguarding and wellbeing of children and young people is of the utmost importance. The children’s homes regulations are clear that restraint can only be used: to prevent injury to any person (including the child …

#30 — Reduce visibility of security guards in Jobcentres, ensuring a more welcoming entry experience.

Work and Pensions Committee

Recommendation: Jobseekers are not criminals and shouldn’t be greeted at Jobcentres by security guards. DWP should make security guards much less visible in Jobcentres, with a more welcoming presence when people enter. (Recommendation, Paragraph 133)

Gov response: Partially accept DWP recognises the importance of a supportive and welcoming environment for our customers, however we also need to strike the right balance to ensure safety for customers and colleagues. This approach does not …

Partially Accepted

#27 — Jobcentre environments often lack accessibility and welcome, undermining efforts to support claimants.

Work and Pensions Committee

Recommendation: Jobcentres are not places that people want to go to. They are often run-down and lack basic facilities, including accessibility features. An intimidating security presence can create additional barriers for some. It will be important that when people walk through …

Gov response: Accept Through capital investment, DWP is committed to transforming our Jobcentre spaces so that our physical infrastructure is adaptable and responsive to the needs of our customers, colleagues, and local and national partners. The Workplace …

#19 — Create new Establishment Payment for community pharmacies to develop patient consultation spaces.

Health and Social Care Committee

Recommendation: We recommend the creation of a new “Establishment Payment” to be paid to eligible community pharmacies to support the development of consultation spaces for patients. This funding should be targeted at pharmacies that are the most reliant on NHS work …

Gov response: In line with the ICS People Function guidance (Report template – NHSI website (england.nhs.uk)), the role of pharmacy leadership within ICBs is clear. The development of a one pharmacy workforce approach, within the multidisciplinary team …

#18 — Support for smaller pharmacies is needed to provide private clinical consultation spaces.

Health and Social Care Committee

Recommendation: Community pharmacies offering clinical services must have private, comfortable spaces in which to see patients. We acknowledge the minister’s comments around pharmacies being private businesses, but they are ultimately expected to provide NHS services. As the expanding availability of clinical …

Gov response: As set out above, this summer we will publish a refreshed Long Term Workforce Plan. The NHS has for years been facing chronic workforce shortages and we have to be honest that bringing in the …

Partially Accepted

#9 — FGM survivors experience shame in healthcare due to inadequate cultural sensitivity training.

Women and Equalities Committee

Recommendation: Evidence suggests some FGM survivors are experiencing shame or humiliation in healthcare settings, reducing the likelihood of them engaging further with healthcare services essential to their physical and mental wellbeing. Training for midwives and healthcare professionals is not mandatory and …

Gov response: Response: It is vital that all professionals with statutory safeguarding responsibilities such as the police, teachers and healthcare professionals have the right training and framework to identify victims and perpetrators of FGM and manage them …

#11 — Implement urgent NHS training challenging racial biases to improve reproductive healthcare in primary care.

Women and Equalities Committee

Recommendation: The NHS needs to urgently implement a training programme to improve the experience of treatment and diagnosis in primary care for women, girls, trans and non-binary people with reproductive ill health. Improving early diagnosis, including through the provision of follow …

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 …

Public Accounts Committee

Recommendation: There is a risk that the new Hospital 2.0 design might not benefit some patients or may add cost. The Hospital 2.0 design was originally due to be ready in December 2023 but, following multiple delays, the Department will not …

Response Pending

Science, Innovation and Technology Committee

Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …

Gov response: The experience of the demands placed on the NHS during the COVID-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS. …

Under Consideration

Science, Innovation and Technology Committee

Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …

Gov response: The government accepts this recommendation. NHS England is committed to developing and publishing new protocols for infection prevention and control in pandemics, covering staffing, bed capacity, and physical infrastructure. In developing these protocols, NHS England …

Under Consideration

Public Accounts Committee

Recommendation: The Department assumes that these single bedrooms will be more efficient, reducing the average patient length of stay by 0.5% annually, plus an additional one-off reduction of 8% to 10% when the new hospital schemes open. However, some research has …

Response Pending

Northern Ireland Affairs Committee

Recommendation: We acknowledge that our direct responsibility is to scrutinise the work of the Northern Ireland Office of the UK Government rather than The Executive Office of the Northern Ireland Executive, but many of the findings of our report bear upon …

No Published Response

CQC Inspection Actions (64) — showing 50 strongest matches

The provider did not ensure that people were treated with dignity and respect.

Reside at Southwood

People's dignity was not promoted and protected and people's choices and decisions were not respected.

Haisthorpe House

The provider must ensure people who used services always have their dignity and independence assured by making suitable arrangements to treat people with consideration and respect.

The provider must ensure people are treated with dignity and respect.

The provider must ensure staff always treat people with respect, and uphold their dignity and privacy.

People were not always treated with dignity and respect. 10(1)

The registered person had not made suitable arrangements to ensure that personal and confidential information was stored securely and that people were treated with people with dignity and respect.

Wrottesley House

The provider must ensure people's dignity is upheld and they are consistently treated with respect.

The Peter Gidney Neurodisability Centre

We recommend that the provider ensures that people's dignity and privacy is preserved at all times.

The provider must ensure that patient's rights to privacy and dignity are protected. Staff must acknowledge patients' presence and ensure they are always correctly addressed and not referred to as initials or room numbers.

People were not treated with dignity and respect at all times.

The provider should ensure that the privacy and dignity of women is maintained at all times.

Lords Care Solutions Stoke On Trent

Regulation 10 HSCA RA Regulations 2014 Dignity and respect

Heritage Healthcare-Middlesbrough

The provider must ensure people's privacy and dignity is always maintained.

Georgiana Care Home

People were not always being treated with kindness and compassion and their privacy and dignity was not always being respected.

Cygnet Bury Hudson

The service must ensure that privacy and dignity of patients is maintained at all times. Seclusion suites must have easy access to bathroom facilities and outside space.

People who lived at the home did not always have their dignity respected.

The provider had failed to ensure people were treated with dignity and respect. Staff did not always recognise, understand or respond to people's needs.

People were not always treated with dignity and respect.

Woodland Care Home

Service users must be treated with dignity and respect.

The Homestead (Crowthorne) Limited

The registered person failed to ensure people are treated with dignity and respect at all times.

People's daily notes were not always written in a positive way. This showed a lack of respect and understanding by staff of how the person was presenting, and if there were underlying issues causing this change in their behaviour.

St.Theresa's Nursing Home

The provider must ensure that the care and treatment of service users is appropriate and meets their needs, including ensuring continence aids are prescribed and used to meet individual needs, and are not shared communally, to respect people's dignity.

St.Theresa's Nursing Home

The provider must ensure that service users are treated with dignity and respect, and their choices in relation to their care needs are always respected.

Reside at Southwood

People's dignity was not promoted and respected.

Precious Nursing & Residential Home

The provider must ensure people are treated with dignity and respect.

Oakleigh House Nursing Home

Services users were not treated with dignity and respect. Regulation 10 (1).

Oaklands Care Home

The provider must ensure people are afforded dignity and respect by staff.

The provider must ensure that all service users are treated with dignity and respect, staff always ensure the privacy of the service user, and support their autonomy, independence and involvement in the community of the service user.

The provider must ensure people are treated respectfully and that their dignity and independence is promoted.

Highfield House Residential Home

The provider must ensure people and their possessions are always treated with dignity and respect.

Haisthorpe House

People who use the service did not always have their dignity and independence assured because the provider had not made suitable arrangements to treat people with consideration and respect.

Goldenley Care Home

The provider must ensure that service users are treated with dignity and respect at all times.

Floron Residential Home for the Elderly

The provider failed to ensure people had their dignity respected at all times. This was a breach of Regulation 10 (Dignity and Respect) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider must ensure that people’s dignity is respected and that they are involved in their care, including when carrying out personal care tasks such as weighing, by ensuring privacy.

Bellevue Healthcare Limited

The provider must ensure people's privacy and dignity are consistently maintained, and that people are not isolated and have appropriate means to communicate and call for assistance.

The provider must ensure people are always treated with dignity and respect, including ensuring appropriate conduct from all staff and respecting people's choices about their care.

Attwood's Manor Care Home

The provider must ensure that people are always treated with dignity and respect.

Ashbourne House - Torquay

Service users were not always treated with dignity and respect.

Baby Bump Limited

The service should consider having a privacy screen in the scanning room to ensure the privacy and dignity of women using the service.

Universal Care - Beaconsfield

The provider failed to ensure people's privacy was routinely upheld.

The provider must ensure service users are always treated with dignity and respect.

Beech House - Basildon

The provider must ensure people are always treated with dignity and respect.

BMI Southend Private Hospital

The provider should undertake further work to improve the area where patient confidential information is discussed to ensure the privacy and dignity of patients.

V&C Family Care Ltd

Service users must be treated with dignity and respect. Without limiting paragraph (1), the things which a registered person is required to do to comply with paragraph (1) include in particular— ensuring the privacy of the service user; supporting the …

Quality Care Management Limited

The registered person must ensure people are treated with dignity and respect and ensure people's privacy, dignity and independence is maintained.

Mead Lodge Residential Care

1.Service users must be treated with dignity and respect. 2.Without limiting paragraph (1), the things which a registered person is required to do to comply with paragraph (1) include in particular— a.ensuring the privacy of the service user; b.supporting the …

Leopold Muller Home

Care and treatment of service users were not always treated with dignity and respect that considered their protected characteristics. This is a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Fairglen Residential Home

The provider must ensure people are treated with dignity and respect at all times.

The provider must take action to ensure suitable arrangements were in place to ensure the dignity; privacy and independence of people using the service were considered and respected.

PPO Death in Custody Recommendations (3)

The Head of Healthcare

The Head of Healthcare should ensure that, wherever possible, consultations and assessments with prisoners are carried out in private and if this cannot happen, the reason is clearly documented.

The Governor and Head of Healthcare

The Governor and Head of Healthcare should ensure that staff are reminded that during a medical emergency and in the event of a prisoner’s death, the conduct and language staff use should be professional and reflect the seriousness of the …

The Governor of Isle of Man Prison

The Governor should consider establishing a protocol with the Isle of Man Constabulary to ensure that following a death in custody the deceased’s body is moved back into their cell for dignity, if there is no suspicion of a crime.

IMB Annual Reports (1)

Scotland and Northern Ireland short-term holding facilities (STHF) (2025)

This report monitors Short-term Holding Facilities (STHFs) in Scotland and Northern Ireland, highlighting significant variations in standards and persistent concerns despite positive staff interactions at times. Key issues include a lack of independent oversight for Controlled Waiting Areas, the continued mixed-sex detention at Larne House, and inconsistent, often inadequate, healthcare provisions, particularly the removal of prescription medication. The Board also raised concerns about substandard accommodation, excessively long detention periods in unsuitable conditions, and a strikingly low number of formal complaints, indicating systemic barriers to raising grievances.

PRISON Key concerns

IMB Recommendations (88) — showing 50 strongest matches

London STHF (2024)

A solution needs to be found to give people waiting in the CWAs more privacy, and the CWA in T2 needs to be enlarged.

There should be capital investment to end the practice of men cell sharing, with an open toilet in the space where they are expected to sleep, eat and live; this would reduce friction between prisoners and increase prisoner respect and engagement with the regime. This is an inhumane practice.

Ministry of Justice

Downview (2023)

There are no privacy curtains in the consulting rooms in healthcare (section 6).

Governor / Director

North West and Midlands STHF (2025)

The Board is concerned at the practice of leaving detained people in the CWA, and recommends that they should always be afforded the dignity, privacy and relative comfort of being moved into the holding room where there are toilets and other facilities to help them rest while being detained (see section 5/Fair and humane treatment).

Foston Hall (2023)

The medication dispensing hatch remains unfit for purpose, with prisoners queuing outside in all weathers and not being assured of privacy if the queue isn’t well-managed. When will this be addressed?

Governor / Director

The Board is concerned about the practice of potentially using an escort chain or handcuff of a prisoner to an officer during a breast screening.

London STHF (2024)

The Board has been asking for toilet seats in all terminal holding rooms for the last few years and we would like to see this issue finally resolved.

The Board would like to see a policy which states that the use of escort chains for prisoners during intimate medical examinations or confidential consultations outside the prison be the exception rather than the norm (6.1).

North West and Midlands STHF (2025)

The Board is concerned that a holding room at Birmingham Airport has been decommissioned and turned into a storeroom. When the Family Room is cold and draughty, detained individuals have been moved into a small room, which compromises their comfort and wellbeing.

Wormwood Scrubs (2020)

Can the use of escort chains at a local level be reviewed – in particular their use for very elderly or sick prisoners?

Governor / Director

Winchester (2021)

What is the prison service doing to hasten the upgrade to the healthcare bathroom and shower area which should be condemned? This work is very long overdue and the need for it was raised in our last two annual reports. (See section 6.3).

Wandsworth (2021)

The lack of adequate kit was a recurrent issue. This included frequently reported shortages of kettles, bedding and clothing. The Board was also concerned about the number of complaints concerning the lack of privacy curtains in shared cells. What is being done to rectify this very unsatisfactory situation?

Governor / Director

Heathrow and City airports Short Term Holding Facilities (2021)

The Home Office should progress the provision of a shower in Terminal 5 to comply with the National Holding Room Standards.

Scotland and Northern Ireland Short-Term Holding Facilities (2022)

We recommend that the bedroom accommodation is improved, thus affording appropriate sleeping accommodation and facilities for private time. The outcome would be the fair and humane detention of each detained person.

Governor / Director

London Heathrow and City Airports (2022)

[London Heathrow Airport Terminal 5] The Board repeats its recommendation that the Home Office should substantially improve the facilities for families and children in Terminal 5. These are currently excessively cramped, and they lack an integrated toilet, shower and baby-changing facilities. (See paragraphs 4.3.46 – 4.3.48)

Accommodation remains a key issue in the prison, with particular regard to decency, disability and dignity, given the limited access to bathrooms and toilets, and the ongoing maintenance issues in the 17 residential houses. What consideration has been given to the option of competitive tendering for large scale maintenance and refurbishment projects to enable a more timely solution to these …

Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)

The Board wishes to see target dates for the implementation and completion of work to provide safe and private facilities for women in Larne House RSTHF, as well as the upgrading of all bedrooms Larne House in line with the trail, re-equipped room.

The Board repeats this view: that forcing men to share cell accommodation designed for single occupancy and which contains toilet and washing facilities with little or no privacy is neither decent nor fair. The requirement to insist on such use reflects poorly on HMPPS.

Dartmoor (2023)

Currently 98 prisoners at HMP Dartmoor are being held in shared, cramped cells lacking furniture, originally designed to accommodate one person. The Independent Monitoring Board regards this as inhumane, unjust and unsustainable. For how long will the prison be asked to accommodate prisoners in these single cells, and can the Minister provide any assurance that there will be no further …

Ministry of Justice

Belmarsh (2023)

The phone in the communal area of HSU is near the desk used by staff which prevents prisoners from having their phone calls in private, could arrangements be made to improve soundproofing around HSU phone or move it away from the staff desk?

Governor / Director

Portland (2024)

What will the Minister do to increase funding to address overcrowding in the prison and eliminate doubling up in cells designed for one individual, impacting personal decency and privacy. Overcrowding also impacts the ability of the prison to transfer prisoners to other prisons that offer the training required to support their release.

Ministry of Justice

North West and Midlands STHF (2024)

The Board is concerned at the practice of leaving detained persons in the Controlled Waiting Areas, and recommends that they should always be afforded the dignity, privacy and relative comfort of being moved into the Holding Room where there are toilets and other facilities to help them rest while being detained (see section 2.3.2.4).

London STHF (2024)

The temperature problems in the holding rooms, both at London Heathrow and London City Airport, need to be resolved. The Board would like to see DCOs be given some form of control, either by being able to directly adjust the temperature or by asking someone to adjust the temperature at their request.

The Board recommends that this situation [the very poor waiting facilities for prisoners in the healthcare department of the prison] is addressed as a priority. It is understood that improving this waiting area would require substantial funding and work but, after so many years of complaints, it is time that the problem is resolved.

Foston Hall (2024)

Prisoners continue to queue outside the medication dispensing hatch, whatever the weather, with no shelter. When will shelter be provided for them?

Governor / Director

South and East Short Term Holding Facilities (STHF) (2025)

The Board recommends where floor space is sufficient, such as at Gatwick North and South main holding rooms, that the adequate provision of sleeping mattresses should be reviewed, as noted in 5.1.

South and East Short Term Holding Facilities (STHF) (2025)

The Board recommends that the Minister review the accommodation capacity, especially as noted in 4.3 and 5.1 at Luton and Stansted. There are an increasing number of people held overnight at the STHFs, which are not designed for overnight accommodation and, in some places, do not provide a dignified and humane space and where the only hot food available at …

North West and Midlands STHF (2025)

We recommend that the bed capacity for women in increased. Bedroom 7 in Manchester RSTHF, which has been designated for their use, is on a corridor where all the male bedrooms and male showers and toilets are located. The risk of possible physical harm to, and abuse of, women in this location has, therefore increased, in the Board’s view. We …

Governor / Director

Yet again, the Board has raised concerns about the levels of overcrowding and its impact on the dignity of prisoners. Yet again, we have received answers offering no hope of improvement. When will the Minister actually resolve this issue? (5.1.1)

Ministry of Justice

Winchester (2020)

Will the Governor endeavour to solve the problem of the exercise yard for vulnerable prisoners being overlooked by B and C wings (see section 4.4)?

Governor / Director

Will the Prison Service review its quality assurance arrangements to improve the effectiveness of GFSL in providing an efficient and responsive maintenance service which supports the Governor’s efforts to embed a dignity and decency agenda? (See paragraph 3.2.5).

Belmarsh (2020)

Will the prison take steps to improve the environment of the outpatients holding room (see section 6.2)?

Governor / Director

Winchester (2021)

More clinical space is needed on the wings, especially for confidential mental health consultations. When will this be facilitated? (See section 6.3).

Governor / Director

Winchester (2021)

What is the Minister’s plan to resolve the issue of permanent cell overcrowding and the fact that prison service instruction (PSI) 17/2012 states prisoners must be ‘able to use the wc with some privacy’ (see sections 3.2, 4.4, 5.1), which is impossible to achieve in HMP Winchester?

Ministry of Justice

The Board’s findings that almost 60% of survey respondents declared that they did not normally receive weekly bedding changes was disappointing, and a worse finding than previously found, when the response was evenly split. The Board draws the Governor’s attention to this finding and hopes that measures will be put in place to achieve a weekly bedding change as a …

Governor / Director

The Board has been surprised to discover how few prisoners had had cell acceptance forms provided on their reception. Proper procedural implementation of this requirement would underline the prison’s acceptance of this practical demonstration of decency. The Board asks that an operational review be held into this identified failure in decency management (see section 5.1).

Governor / Director

Heathrow and City airports Short Term Holding Facilities (2021)

The Board repeats its recommendation that the Home Office should substantially improve the facilities for families and children in Terminal 5. These are currently excessively cramped and they lack integrated toilet, shower and baby-changing facilities.

London Heathrow and City Airports (2022)

[London Heathrow Airport] The Board recommends that if a holding room is being reconstructed, consideration be given to accommodating men and women separately, as recommended by HM Inspectorate of Prisons. (See paragraphs 4.2.14 and 4.2.15)

The Board would ask the minister to consider the issues of insufficient capacity within the prison estate which continues to see prisoners housed in double cells which are inadequate both in size and design for this purpose and impinge upon the right to privacy and dignity;

Ministry of Justice

South and East 2022-23 Short Term Holding Facilities (STHF) (2023)

The Board acknowledges that the seating in the family room in Gatwick North was replaced in March 2022 however we are unaware of whether the promised review by Border Force South and Gatwick Airport Limited regarding the overall accommodation in Gatwick North has taken place (please note our comments in sections 4.3 and 4.4) and if not, we recommend that …

South and East 2022-23 Short Term Holding Facilities (STHF) (2023)

We also recommend that an adequate supply of sleeping mats, pillows and bedding be provided within all airport holding rooms without further delay.

Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)

The decor and general furnishing at Edinburgh airport HRs are in real need of redecoration. We understand that this work is being looked at for implementation. We are also waiting the installation of a flight monitor and the replacement of the old TV sets in the two holding rooms.

Kent Coast Short Term Holding Facilities (STHF) (2023)

Try to make induction booths more private, so detained people, can feel at ease answering personal questions.

Consider the issues of insufficient capacity within the prison estate which continues to see prisoners housed in double cells which are inadequate both in size and design for this purpose and impinge upon the right to privacy and dignity.

Ministry of Justice

For many years, complaints have been registered about the very inadequate waiting area in the healthcare unit. This needs to be addressed urgently.

Whilst appreciating the fabric of the HMP Cardiff site plays a large part in this, what can be done to address prisoners having no access to out of cell space to eat food, which currently means in shared cells both men must eat with a shared toilet in the space?

South and East 2023-24 Short Term Holding Facilities (STHF) (2024)

The Board recommends where floor space is sufficient such as Gatwick North and South main holding rooms, that the adequate provision of sleeping mattresses should be reviewed.

Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)

We reiterate our previous recommendation that the provision of safe and private facilities for women within Larne House RSTHF remains outstanding. The Home Office previously committed to undertake work to ensure that women were accommodated separately from men. The Board recommends work is urgently completed with the outcome that the safety and dignity of women in detention can be assured.

Moorland (2024)

How does the Minister plan to reduce prison overcrowding, given the repeated increases in operating capacity necessitating the conversion of single cells to doubles and the impact on dignity and wellbeing?

Ministry of Justice

Substantial investment is required to bring existing accommodation up to an acceptable standard. Aspects, including access to clean, working showers and reliable heating are insufficient and provision continues to deteriorate.

Ministry of Justice

Health Investigations (1)

Themes and lessons learnt from NHS investigations into matters relating … — Rec R1

All NHS hospital trusts should develop a policy for agreeing to and managing visits by celebrities, VIPs and other official visitors. The policy should apply to all such visits without exception.

national Accepted

Article 2 Learning Points (2)

The prison must ensure that when a prisoner is on a bed watch in hospital and in a poor state of health, following an incident of life threatening self-harm, they achieve a balanced risk assessment of the need to have prison officers present to protect the public and the prisoner’s …

HMP Altcourse Accepted

Independent Monitoring Boards across NOMS may wish to consider the merits or otherwise of visiting prisoners whilst they are temporarily resident in external settings such as hospitals. This could be particularly relevant if a prisoner is absent from the prison for a protracted period of time.

Independent Monitoring Boards Rejected

Detention Investigations (18)

Assessment of government progress in implementing the report on the … — Rec 21

Waiting environments for medication distribution should be reviewed to ensure privacy and dignity, and support personal safety.

Immigration Detention

Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R30

Pregnant residents should be allowed to eat their meals away from the main dining rooms without having to obtain permission from healthcare staff.

Immigration Detention

Assessment of government progress in implementing the report on the … — Rec 7

No immigration detention facility should be built in future with a barely screened toilet inside a shared room, and this set-up should be upgraded in all existing facilities.

Immigration Detention

Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 32

Group 4 (and other contractors) provides the cheapest phone service possible to detainees and that it ensures its phone systems fully meet the needs of detainees.

Immigration Detention

Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 31

the food be checked daily for quality and quantity by the contract monitor.

Immigration Detention

Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 36

I recommend that the Immigration Service considers introducing music or radio into vans and that detainees be offered something to read or do during the wait.

Immigration Detention

Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 11

I recommend that staff are instructed not to touch detainees or their beds while waking them up.

Immigration Detention

Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 3

I recommend that washing, eating and toilet facilities be made available at all sites where detainees are likely to be held for more than an hour.

Immigration Detention

Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R26

G4S managers and the SMT should: • improve the environment in the reception area at Brook House and make it more welcoming; • consider how all new arrivals can be interviewed in privacy; and • agree with the Home Office how they will provide showers for new arrivals. (To be …

Immigration Detention

Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 32

I recommend that staff be trained to ask the detainee by what name he/she would like to be called and to check with him/her their pronunciation of the name.

Immigration Detention

Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R20

Serco should consider how residents might be given greater opportunities to cater for themselves, including by expanding the cultural kitchen facilities, the choice of foods in the shop and providing facilities for residents to store and cook food and make snacks for themselves.

Immigration Detention

Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R16

Managers should continue to look for opportunities to improve the physical environment at Yarl’s Wood and make it less prison-like. In particular they should discuss with the Home office whether they can give residents access to more open space and whether they can increase natural light in the corridors and …

Immigration Detention

Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R13

Managers should review policy and procedure in relation to entering residents’ rooms and interviews with and checks on residents, particularly at night, to ensure that interviews and checks are as thorough as necessary and carried out in a consistently by all staff.

Immigration Detention

Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 66

a single lock-down time be introduced across the detention estate, but that detainees be allowed to smoke in their rooms and that a television is provided in each room or dormitory.

Immigration Detention

Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 65

courtesy keys and locks be introduced in removal centres.

Immigration Detention

Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 9

I recommend that IND considers what information might usefully be given to detainees about Use of Force and in what form. Care must be taken to avoid suggestions of oppression or intimidation.

Immigration Detention

Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 6

I recommend that the Immigration Service urgently considers the provision of pagers to detainees at Oakington.

Immigration Detention

Review into the Welfare in Detention of Vulnerable Persons — Rec 56

I recommend that the creation of care suites across the IRC estate should be taken forward as a priority.

Immigration Detention

PHSO Casework Decisions (147)

P-002266 — West Midlands Ambulance Service University NHS Foundation Trust

Ms U says paramedics came to her home in April 2021 with a television crew. She says her mother had stopped breathing and needed urgent assistance and filming was not appropriate.

NHS in England Oct 2023

P-002938 — University Hospitals of Derby and Burton NHS Foundation …

Mrs A complains about the care and treatment the Trust gave to her husband. She says it put a Do Not Attempt Resuscitation (DNAR) Order in place without the family’s input or knowledge. She also complains it wrongly gave him opioid pain relief and did not monitor him for side …

NHS in England Sep 2024

P-003610 — Norfolk and Suffolk NHS Foundation Trust

Ms A complains that CCTV images the Trust took breached her privacy and dignity in June 2022 and again in September 2023.

NHS in England Jun 2025

P-004511 — North Tees and Hartlepool NHS Foundation Trust

Miss L complains the Trust did an intimate examination after the birth of her child without properly explaining it or that it may be painful.

NHS in England Partly Upheld Dec 2025

P-001121 — East Suffolk and North Essex NHS Foundation Trust

Mrs L complains about the service she and Ms U received from East Suffolk and North Essex NHS Foundation Trust on 15 November 2020. She complains staff refused to allow her to accompany Ms U into ED and on to the ward, were rude to her and woke her up …

NHS in England Sep 2021

P-001396 — Royal Free London NHS Foundation Trust

Mrs U complains that in December 2020, the Royal Free London NHS Foundation Trust would not provide her mother with mittens to prevent her from removing her oxygen mask. As a result, Mrs U said her mother died as she was not given the chance to get the oxygen she …

NHS in England May 2022

P-001386 — Milton Keynes University NHS Foundation Trust

Mrs A complains that Milton Keynes University Hospital NHS Foundation Trust added a do not attempt cardiopulmonary resuscitation (DNACPR) order to her medical record without her explicit consent, and twice did not secure the brake on her commode when she was an inpatient in April 2020.

NHS in England May 2022

P-001585 — A dental practice in the Stockton-on-Tees area

Ms O complains that a receptionist at the Practice asked her about her COVID-19 vaccination status on a reminder call about an upcoming appointment. Ms O complains the Practice then cancelled her appointment

NHS in England Aug 2022

P-001974 — A care home in the Northamptonshire area

Mrs A and Mrs K complain the care home took their father to hospital against his will and did not tell the family.

NHS in England Sep 2022

P-001694 — HCRG Care Group

Mrs O complains carers were unprofessional and mistreated her father, Mr A, by refusing to change his incontinence pad and pulling his arm. She says staff listened to the family's conversations and reported them. She also complains the service would not give Mr A a male carer and dismissed the …

NHS in England Nov 2022

P-002302 — Sherwood Forest Hospitals NHS Foundation Trust

Ms P complains about the Trust's care and treatment when she went to the emergency department in January 2020. She complains nursing staff took her baby away from her without her permission and treated her baby although they were not the patient.

NHS in England Nov 2023

P-002365 — King's College Hospital NHS Foundation Trust

Mrs D complains on behalf of her father about how the Trust used do not attempt cardiopulmonary resuscitation (DNACPR) notices. She says a DNACPR form was completed without her father’s or his family’s consent, his records incorrectly say he consented to the DNACPR, his wishes to be resuscitated were ignored …

NHS in England Dec 2023

P-002523 — Chelsea and Westminster Hospital NHS Foundation Trust

Mrs U complains the Trust shaved her hair during an operation to remove cysts and when she asked for this not to happen, the Trust only removed a few of the cysts. She also complains the Trust’s investigation into her complaint was one-sided and unfair.

NHS in England Mar 2024

P-002646 — Manchester University NHS Foundation Trust

Mrs G complains the Trust did not contact her when her father had a fall and another time it left him lying on a bed pan for over two hours. She complains it did not tell her when her father died but contacted someone else and gave them her father's …

NHS in England Upheld May 2024

P-002760 — Royal Devon University Healthcare NHS Foundation Trust

Mr R complains that during a hospital admission the Trust left his father in unclean bed sheets, gave him cold food and left him in a room with the window open on one of the coldest nights of the year, He also complains about the way Trust staff communicated that …

NHS in England Jul 2024

P-002752 — A practice in the City of Derby area

Mr and Mrs R complain about the care and treatment the Trust provided during Mrs R's pregnancy and the birth. They complain the staff did not direct Mrs R to services, it did not support her to write a birth plan and staff did not tell her what was happening, …

NHS in England Partly Upheld Jul 2024

P-003285 — Warrington and Halton Hospitals NHS Foundation Trust

Miss E complains about the Trust’s treatment during her labour in October 2021. She complains staff ignored her wishes and gave her medical procedures without her consent.

NHS in England Upheld Jul 2024

P-002952 — Mid Yorkshire Teaching NHS Trust

Mrs A complains Mid Yorkshire Teaching NHS Trust sent Mr A home when his diabetes was not stable. Mrs A also says it incorrectly informed her about his pneumonia diagnosis and did not tell her how unwell Mr A was when it put a DNACPR in place.

NHS in England Sep 2024

P-002922 — United Lincolnshire Hospitals NHS Trust

Mrs G complains the Trust did not look properly manage her husband’s diabetes when he was a hospital inpatient. She also complains it did not properly account for her wishes when making decisions about resuscitation and end of life care.

NHS in England Upheld Sep 2024

P-002945 — Manchester University NHS Foundation Trust

Miss U complains about the care and treatment when she was sectioned under the Mental Health Act. She said staff used inappropriate physical force and did not tell her about several aspects of her treatment.

NHS in England Sep 2024

P-002980 — Sandwell and West Birmingham Hospitals NHS Trust

Mr K complains that in December 2022 staff moved his mother from a side room to a bed on a shared ward.

NHS in England Sep 2024

P-002926 — University Hospitals Birmingham NHS Foundation Trust

Miss I complains about the care and treatment given to her father in 2021. Miss I complains her father was able-bodied when he went into hospital, but when he left he was disabled and he died shortly after. She also says the family felt pressured into accepting a Do Not …

NHS in England Sep 2024

P-002987 — University Hospitals Coventry and Warwickshire NHS Trust

Mrs A complains A&E staff incorrectly moved her husband when they should have continued monitoring him before admitting him to a ward for further investigations. She complains about the treatment after this and that a clinician spoke to her husband about implementing a DNACPR order when he was alone and …

NHS in England Partly Upheld Sep 2024

P-003362 — Northern Lincolnshire and Goole NHS Foundation Trust

Miss S complains the Trust failed to disclose her mother’s diagnosis to her and the family, failed to meet her mother’s nutrition and hydration needs and that the planning, communication and symptom relief during her mother’s end of life care was not in line with what was needed.

NHS in England Upheld Feb 2025

P-003523 — Taunton and Somerset NHS Foundation Trust

Mrs A complains the Trust inappropriately catheterised her late husband without his consent in February 2018.

NHS in England Apr 2025

P-003700 — Sussex Partnership NHS Foundation Trust

Ms F complains between 7 and 21 December 2023, Dr A discussed E’s needs with a neighbouring service without due consideration for E’s history with that service, or without seeking consent to do so first.

NHS in England Jul 2025

P-004430 — Dartford and Gravesham NHS Trust

Ms G complains the Trust did not provide appropriate nutrition, hydration, hygiene and personal care to Mr H. She says as a result of failings in the Trust her father lacked dignity, deteriorated and suffered an early death.

NHS in England Dec 2025

P-004473 — University Hospitals Birmingham NHS Foundation Trust

Mrs U complains about the following aspects of the care and treatment her sister, Ms A received from the Trust. Mrs U complains the Trust did not administer pain relief to Ms A, did not attend to Ms A's for help with her personal care in a timely manner, and …

NHS in England Upheld Dec 2025

P-001067 — Essex Partnership University NHS Foundation Trust

Mr and Mrs A complain that Essex Partnership University NHS Foundation Trust (the Trust) did not communicate with or invite Mr A to any review meetings including the discharge meeting and discharged Mrs A from Hospital too soon. They also complain that when Mrs A went back into the mental …

NHS in England Partly Upheld Apr 2021

P-001112 — University College London Hospitals NHS Foundation Trust

Mr A complained about the Trust’s biopsy of his prostate, his discharge from hospital after surgery and his confidentiality. He also complained about Trust’s handling of his concerns.

NHS in England Upheld Sep 2021

P-001137 — Mid and South Essex NHS Foundation Trust

Mrs W complained about the care the Trust provided to her husband, who died of COVID-19. This includes issues in nursing care, poor communication, and the disposal of Mr W’s belongings following his death.

NHS in England Upheld Oct 2021

P-001233 — Buckinghamshire Healthcare NHS Trust

Ms T complains about aspects of the care provided to her partner, Mr S, at the Trust. Ms T also complains about a lack of communication with her, and a lack of compassion in the end of life care for Mr S.

NHS in England Upheld Dec 2021

P-001238 — Cambridge University Hospitals NHS Foundation Trust

Ms U complained that the Trust did not show compassion or arrange follow-up care when she suffered a miscarriage.

NHS in England Upheld Dec 2021

P-001272 — Manchester University NHS Foundation Trust

Mrs E complained about the care and treatment her mother, Mrs P, received at Manchester University NHS Foundation Trust, including inappropriate discharge, delayed diagnosis of kidney infection, failure to maintain her dignity, and failure to involve Mrs E in her mother's care.

NHS in England Partly Upheld Jan 2022

P-001531 — A dental practice in the Bedfordshire area

Mr A complains that a dentist did not provide him with adequate pain relief and did not listen to him when he said he was in pain during a tooth extraction.

NHS in England Sep 2022

P-001543 — Mersey Care NHS Foundation Trust

Ms O complains that a community mental health nurse at the Trust breached her confidentiality by sharing her personal opinion about her father's care with him.

NHS in England Sep 2022

P-001534 — Gateshead Health NHS Foundation Trust

Mrs I complains about the care provided to her late mother when she was admitted to hospital for an undiagnosed condition. Mrs I complains about staff behaviour and that staff continued to carry out observation checks when her mother was approaching end of life.

NHS in England Sep 2022

P-001570 — Mid and South Essex NHS Foundation Trust

Ms C complains the Trust did not closely watch her father. She says it knew he was agitated and he had taken off his oxygen mask before. She feels the Trust should not have left him in an isolated room where it was difficult for him to call for help. …

NHS in England Oct 2022

P-004561 — Milton Keynes University Hospital NHS Foundation Trust

Mrs Y complains about the care and treatment her mother, Mrs D, received from Milton Keynes University Hospital NHS Foundation Trust between May and July 2023. She raises concerns about delays in pain relief and fluids, poor hygiene practices, inadequate post-surgery pain management, failures in fall prevention, and rough handling …

NHS in England Partly Upheld Jan 2026

P-001722 — Leeds Teaching Hospitals NHS Trust

Miss I complains Trust staff used excessive force and pinned her partner, Mr E, down after he asked to go for a cigarette. She also says Mr E experienced abuse and neglect leaving bruising on his body.

NHS in England Jan 2023

P-001764 — Northampton General Hospital NHS Trust

Ms A complains the Trust should not have allowed her father to go to the toilet unaccompanied and without his oxygen. She also complains it made decisions without discussing treatment with her first and it did not properly communicate the circumstances of her father’s death with her.

NHS in England Jan 2023

P-001741 — Portsmouth Hospitals NHS Trust

Mrs C explains she was just under five months pregnant and had regular cramp-like pain in her lower abdomen. She complains she was told a gynaecologist would come to see her, but she waited hours and was not seen or moved to a bed or room.

NHS in England Partly Upheld Jan 2023

P-001812 — A care home in the Sunderland area

Mrs R complains the home did not give her father good continence and personal care between April and May 2021.

NHS in England Feb 2023

P-001981 — West Hertfordshire Hospitals NHS Trust

Mrs U complains the Trust did not help her husband to shower and he had thrush on his genital area when he was discharged to home. She also complains he caught COVID-19 during a later admission to the Trust and this caused him to have a heart attack and die.

NHS in England May 2023

P-002031 — North East Ambulance Service NHS Foundation Trust

Mrs P complains about the unsafe and undignified way the Trust’s paramedics moved her husband from their home to the ambulance.

NHS in England Jun 2023

P-002259 — South Tees Hospitals NHS Foundation Trust

Mrs R complains that when she was in an induced coma in July 2019 staff did not turn her enough. She also says she reported her symptoms in July 2019 but the Trust delayed investigating and did not diagnose her nerve damage until October 2020.

NHS in England Oct 2023

P-002262 — Chesterfield Royal Hospital NHS Foundation Trust

Mrs U complains that staff in the high dependency unit allowed her mother to die in a traumatic and painful way.

NHS in England Oct 2023

P-002256 — University Hospitals Birmingham NHS Foundation Trust

Mr R complains about how the Trust cared for his father. He says it did not give him support, provide palliative care or give him dignity at the end of his life.

NHS in England Oct 2023

P-002306 — The Dudley Group NHS Foundation Trust

Mrs D complains about the Trust's care and treatment of her mother. She complains the Trust allowed her mother to develop pressure sores, neglected her, kept moving her to different wards and did not communicate well with her family.

NHS in England Nov 2023

P-002466 — University Hospitals Birmingham NHS Foundation Trust

Mrs R complains about the care and treatment the Trust gave to her grandmother in March and April 2022, in respect of her hygiene needs, discharge planning, oxygen therapy and capacity to consent.

NHS in England Upheld Feb 2024

LGO / SPSO Decisions (268)

201104151 — Ayrshire and Arran NHS Board

When Mr C's mother died in hospital, he made arrangements with a funeral home to have her body collected and prepared for cremation. Mr C complained that his mother's body was not released by the hospital until late afternoon two days later. He was particularly upset because he had been …

SPSO (Scottish Public Se… Health Not Upheld Jun 2012

201102748 — Orkney NHS Board

Mrs C received care and treatment from her GP (in a practice administered by the board) in relation to pneumonia, bunion pain and multiple sclerosis. In 2006, Mrs C phoned her GP in the early morning, complaining of being unwell. The GP visited her at home and referred her to …

SPSO (Scottish Public Se… Health Partly Upheld Jun 2012

201102321 — Greater Glasgow and Clyde NHS Board

Mr C complained on behalf of his partner (Ms A) who was a hospital in-patient receiving treatment for schizoaffective disorder (a mental disorder affecting thinking processes and mood). Ms A was prescribed unilateral electroconvulsive therapy (ECT – a treatment that involves sending an electric current through the brain). This was …

SPSO (Scottish Public Se… Health Partly Upheld Jun 2012

201102277 — Forth Valley NHS Board

Mr C made several complaints about the care and treatment he received in hospital, most of which we did not uphold. He said that a communication failure meant that staff were not expecting him when he arrived. However, we found that the staff nurse had been told that he was …

SPSO (Scottish Public Se… Health Partly Upheld Jun 2012

201200240 — A Medical Practice in the Ayrshire and Arran …

Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her …

SPSO (Scottish Public Se… Health Upheld Dec 2012

201204783 — A Housing Association

Mr Cs son (Mr A) had died, leaving a widow and young family. Mr A and his widow were tenants of the housing association. After Mr A died, Mr C handled matters, including contacting the association within days of his son's death. Mr C complained that the rental direct debit …

SPSO (Scottish Public Se… Local Government Partly Upheld Jul 2013

201203403 — A Medical Practice in the Greater Glasgow and …

Ms A was removed from the practice's treatment list. She believed this was inappropriate, and complained to the practice. She remained dissatisfied when she received their response and her partner (Mr C) complained to us on her behalf. When we investigated, we found that the practice had not met the …

SPSO (Scottish Public Se… Health Upheld Jul 2013

201103691 — Ayrshire and Arran NHS Board

Mrs C's late mother (Mrs A) was admitted to hospital following a stroke. She was transferred to another ward a few days later. The day after her transfer to the ward, Mrs C told a nurse that her mother had a headache and needed pain relief. Mrs C said that …

SPSO (Scottish Public Se… Health Not Upheld Jul 2013

201204853 — A Medical Practice in the Forth Valley NHS …

Mr C complained that his medical practice refused to update him on changes in his son (Master A)s medical file, about which his estranged wife had not told him. Mr C also complained that the practice had prevented him from transferring his son to an alternative practice in the area. …

SPSO (Scottish Public Se… Health Not Upheld Sep 2013

201204558 — Grampian NHS Board

Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for …

SPSO (Scottish Public Se… Health Upheld Sep 2013

201204522 — Glasgow Housing Association Ltd

Mr C needed a lot of support with housing matters. He was asked to go to his local housing office about a rent matter and called in, expecting to see one of two officers he had dealt with before, but they had both retired. He was introduced to his new …

SPSO (Scottish Public Se… Local Government Not Upheld Sep 2013

201203006 — Orkney NHS Board

Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical …

SPSO (Scottish Public Se… Health Not Upheld Sep 2013

201300409 — Ayrshire and Arran NHS Board

Ms C complained about her care and treatment during the birth of her son. In particular, she was concerned about the attitude of the midwife - she said that the midwife had snapped at her, had not listened to her and had not explained what was happening. She was concerned …

SPSO (Scottish Public Se… Health Upheld Feb 2014

201401305 — A Dentist in the Lothian NHS Board area

Mrs C complained that part of her dental work was provided on a private basis without her prior knowledge or consent. She said that she was not given a written treatment plan or cost comparison before the treatment was carried out. The dentist said that Mrs C was given a …

SPSO (Scottish Public Se… Health Upheld Jan 2015

201601930 — Lothian NHS Board - Acute Division

Mr C complained that the board failed to provide the results of a scan that he underwent at the Western General Hospital. He said that his GP had not been given the results of the scan, and that when he called the board he was given results over the phone …

SPSO (Scottish Public Se… Health Upheld Jan 2017

201703864 — Grampian NHS Board

Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of …

SPSO (Scottish Public Se… Health Partly Upheld Oct 2018

201703685 — Lothian NHS Board - Acute Division

Mrs C had knee replacement surgery at the Royal Infirmary of Edinburgh. She also underwent manipulation under anaesthetic (MUA - a procedure to try and improve movement) to try and relieve knee stiffness after the operation. Mrs C complained about the board's communication with her following the knee replacement surgery. …

SPSO (Scottish Public Se… Health Upheld Oct 2018

202500059 — Greater Glasgow and Clyde NHS Board - Acute …

C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to …

SPSO (Scottish Public Se… Health Upheld Feb 2026

202304648 — Dumfries and Galloway NHS Board

C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into …

SPSO (Scottish Public Se… Health Not Upheld Feb 2026

21-002-476c — Bupa Care Homes (AKW) Limited (21 002 476c)

Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …

LGO (Local Government & … Health Upheld Jul 2022

21-002-476b — Ardenlea Grove Care Home (21 002 476b)

Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …

LGO (Local Government & … Health Upheld Jul 2022

21-002-476a — University Hospital Birmingham NHS Foundation Trust (21 002 …

Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …

LGO (Local Government & … Health Not Upheld Jul 2022

21-002-476 — Solihull Metropolitan Borough Council

Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …

LGO (Local Government & … Adult Care Services Upheld Jul 2022

201005089 — Lothian NHS Board

Ms C was awaiting reconstructive surgery after treatment for breast cancer. She told us that when she was seen in an out-patients clinic in February 2010 she was led to believe that the waiting time for surgery was about six months. She later found out that the waiting time was …

SPSO (Scottish Public Se… Health Upheld Jul 2011

201004596 — Lanarkshire NHS Board

Mrs C was admitted to a hospital in which her husband was already a patient. She complained that a member of hospital staff wrote in her medical records that her husband was dying, and that a nurse told her daughter this. The Board apologised and took action to stop this …

SPSO (Scottish Public Se… Health Not Upheld Jul 2011

201005373 — Grampian NHS Board

Mr C complained that an employee of Grampian NHS Board passed on negative remarks about him (made by a third party) to his sister-in-law. This was in relation to the search for a care home for their relative, Mr A. The investigation revealed that the information had been relevant to …

SPSO (Scottish Public Se… Health Not Upheld Aug 2011

201005315 — Highland NHS Board

Mrs C complained about the care provided to her by nursing staff during her stay at Raigmore Hospital. In particular she was concerned about the attitude of nursing staff and and about delays in attending to her needs. We did not find sufficient evidence to support her claims that the …

SPSO (Scottish Public Se… Health Not Upheld Aug 2011

201100271 — Ayrshire and Arran NHS Board

Mr C complained about care and treatment provided to his wife, Mrs C. Mrs C was admittted to Accident and Emergency at Ayr Hospital in December 2010 after a fall at her home. She had a suspected fracture. After being assessed, it was confirmed that she had a fractured pelvis. …

SPSO (Scottish Public Se… Health Upheld Oct 2011

201100261 — A Medical Practice, Highland NHS Board

Ms C complained about the care and treatment she received after she registered with a new medical practice. She said that a GP did not carry out a general check of her health and that the action taken by the practice in relation to her symptoms of depression was inconsistent. …

SPSO (Scottish Public Se… Health Not Upheld Oct 2011

201103646 — Tayside NHS Board

Mr C's wife (Mrs C) was admitted as an emergency case to hospital, but passed away the next day. Mr C was unhappy that the board did not contact him to tell him that his wife had died, and that he only found this out when he called to ask …

SPSO (Scottish Public Se… Health Partly Upheld Apr 2012

201200021 — A Medical Practice in the Tayside NHS Board …

Ms C complained that her medical practice had kept information from her about her hospital test results. She also said that when she wrote a formal letter of complaint to the practice they had failed to address the issues she raised. Our investigation found, however, that the practice had correctly …

SPSO (Scottish Public Se… Health Not Upheld Jul 2012

201200239 — A Medical Practice in the Ayrshire and Arran …

Ms A requested that her first appointment with a new medical practice be longer than usual. Ms A was late for the appointment, and when the GP refused to see her she became upset. She wrote a letter about the situation while she was in the practice but this was …

SPSO (Scottish Public Se… Health Partly Upheld Oct 2012

201102610 — Lothian NHS Board

Mrs C complained about the care and treatment her father (Mr A) received while in hospital. Mrs C said that her family were asked to contact the ward on the day of Mr A's operation. She said that when they did this, they were made to feel over-anxious. Mrs C …

SPSO (Scottish Public Se… Health Partly Upheld Oct 2012

201200144 — A Medical Practice in the Fife NHS Board …

Mrs C complained that her mother (Mrs A) had mobility problems, which caused her great difficulty in attending the medical practice. Mrs C wanted an assurance that the GPs would make non-emergency home visits to Mrs A if required. The practice explained that there would have to be a clinical …

SPSO (Scottish Public Se… Health Not Upheld Mar 2013

201203440 — A Medical Practice in the Lothian NHS Board …

Mr C complained about various aspects of his treatment by reception staff and the practice manager when he attended the practice on two occasions. Our investigation found that there had been shortcomings in a number of areas and because of this we upheld the complaint. However, we also noted that …

SPSO (Scottish Public Se… Health Upheld Apr 2013

201101313 — Greater Glasgow and Clyde NHS Board - Acute …

Ms C complained about the care and treatment that her late father (Mr A) received in hospital before his death. She said that staff failed to recognise and manage her father's pain and to act on her concerns about this. During our investigation, we took independent advice from one of …

SPSO (Scottish Public Se… Health Partly Upheld May 2013

201203679 — A Medical Practice in the Highland NHS Board …

Mrs C was unhappy with care and treatment she had received from a doctor at the medical practice, and had tried to avoid consulting him. However, she had to see him for a medication review. She was unhappy about this and raised concerns about the treatment she received from him …

SPSO (Scottish Public Se… Health Not Upheld Jun 2013

201204747 — Forth Valley NHS Board

Mr C, who is a MSP, complained on behalf of Mrs A's family. Mrs A, who was 94, was admitted to hospital with shortness of breath, and chest and back pain. Her family were told that she would be examined for a possible chest infection or a clot on her …

SPSO (Scottish Public Se… Health Partly Upheld Oct 2013

201204951 — An NHS Board

Mr C was being treated for HIV (Human immunodeficiency virus - the virus that causes acquired immunodeficiency syndrome (AIDS)). He was unhappy because the board sent his medication to a family member's home, rather than to his medical practice as requested. A family member opened the package and became aware …

SPSO (Scottish Public Se… Health Upheld Nov 2013

201302758 — A Medical Practice in the Forth Valley NHS …

Mrs C complained about a specific consultation with a GP in her local practice. She attended with a flare-up of her longstanding physical health problems, which included fibromyalgia and osteoarthritis (conditions that cause the muscles and joints to become painful and stiff). She complained that the GP was dismissive of …

SPSO (Scottish Public Se… Health Not Upheld Mar 2014

201302723 — A Medical Practice in the Grampian NHS Board …

Mr C complained about the care and treatment provided to his father (Mr A) by the medical practice after he raised concerns about Mr A's deteriorating health. Specifically, he was concerned that doctors failed to assess his father's deteriorating mental health. Mr A refused to go into respite care, was …

SPSO (Scottish Public Se… Health Not Upheld Mar 2014

201302512 — Lothian NHS Board

Mr C and his mother (Mrs A) received a visit from two community psychiatric nurses (CPNs) who assessed his and his mother's needs. At the end of the interview they mentioned that the results might be shared with colleagues in the social work department. Mr C was at that time …

SPSO (Scottish Public Se… Health Not Upheld Mar 2014

201204540 — Lothian NHS Board

Ms C's late mother (Mrs A) was treated in hospital as an in-patient for illnesses that included pneumonia and chronic heart failure. Ms C complained that during that time the hospital communicated inadequately with her and other family members about Mrs A's medical condition. In particular Ms C said that …

SPSO (Scottish Public Se… Health Not Upheld Mar 2014

201302499 — Lothian NHS Board

Mr C, who is a prisoner, complained about the late supply of medication by the health centre based within the prison. He was also unhappy with the way in which his complaint was handled, saying that he had difficulties obtaining a complaints form and that health centre staff had opened …

SPSO (Scottish Public Se… Health Partly Upheld Apr 2014

201204572 — Lothian NHS Board

Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the …

SPSO (Scottish Public Se… Health Partly Upheld Apr 2014

201306193 — Borders NHS Board

Mrs C told us that her late mother (Mrs A) did not get the care she deserved during the last few hours of her life at Borders General Hospital. She said that at other times the standard of care provided during her mother's stay in hospital had been good or …

SPSO (Scottish Public Se… Health Upheld Sep 2014

201405741 — Lanarkshire NHS Board

Mr C complained that his prison health centre revealed information about his health to Scottish Prison Service (SPS) staff. Mr C also complained about the board's response to his complaint. We looked at the board's investigation, and at an SPS investigation that was carried out in partnership with the board. …

SPSO (Scottish Public Se… Health Not Upheld Jul 2015

201404431 — Fife NHS Board

Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop …

SPSO (Scottish Public Se… Health Upheld Jul 2015

201305515 — West Lothian Council

Miss C, a council tenant, complained about various aspects of the services she had received from the council. She complained that a warning marker had been put on her records, and had not been reviewed in line with policy. This marker indicated that staff should visit her in pairs. The …

SPSO (Scottish Public Se… Local Government Partly Upheld Jul 2015

201404470 — Highland NHS Board

Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and …

SPSO (Scottish Public Se… Health Partly Upheld Aug 2015

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