Patient safety governance
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
1,161 items
12 sources
10 inquiries
Source spread
Where this theme appears
Patient safety governance has been flagged across 12 independent accountability sources:
270 inquiry recs
145 PFD reports
25 committee recs
213 CQC actions
7 PHSO recs
13 IMB recs
2 patient safety alerts
5 Article 2 learning points
1 detention investigation rec
20 PHSO decisions
444 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 (270) — showing 50 strongest matches
F68 — Focus on compliance with fundamental standards
Recommendation: No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F67 — Focus on compliance with fundamental standards
Recommendation: The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F66 — Improving contribution of stakeholder opinions
Recommendation: The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F65 — Quality of care as a pre-condition for foundation trust applications
Recommendation: The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F64 — Authorisation of foundation trusts
Recommendation: The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F63 — Improved transparency
Recommendation: Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F62 — Improved patient focus
Recommendation: For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F61 — Consolidation of regulatory functions
Recommendation: A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F60 — Consolidation of regulatory functions
Recommendation: The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F59 — Care Quality Commission independence strategy and culture
Recommendation: Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F58 — Care Quality Commission independence strategy and culture
Recommendation: Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F57 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F56 — Care Quality Commission independence strategy and culture
Recommendation: The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F55 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F54 — Care Quality Commission independence strategy and culture
Recommendation: Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F53 — Care Quality Commission independence strategy and culture
Recommendation: Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F52 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F51 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F50 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F49 — Enhancement of monitoring and the importance of inspection
Recommendation: Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F48 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F47 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F46 — Use of information about compliance by regulator from: Quality and risk profiles
Recommendation: The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F45 — Use of information about compliance by regulator from: Inquests
Recommendation: The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F44 — Use of information about compliance by regulator from: Media
Recommendation: Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F43 — Use of information about compliance by regulator from: Media
Recommendation: Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F41 — Use of information about compliance by regulator from: Patient safety alerts
Recommendation: The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F40 — Use of information about compliance by regulator from: Complaints
Recommendation: It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F39 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F38 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F37 — Use of information about compliance by regulator from: Quality accounts
Recommendation: Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F36 — Use of information for effective regulation
Recommendation: A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F35 — Need to share information between regulators
Recommendation: Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F34 — Interim measures
Recommendation: Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F33 — Interim measures
Recommendation: Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F32 — Interim measures
Recommendation: Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F6 — Clarity of values and principles
Recommendation: The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F5 — Clarity of values and principles
Recommendation: In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; They will do everything in their power to protect patients from avoidable harm; They will be honest and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F4 — Clarity of values and principles
Recommendation: The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
BRIS-121 — Assign executive and non-executive board members responsibility for clinical safety strategy.
Recommendation: At the level of individual trusts, an executive member of the board should have the responsibility for putting into operation the trust’s strategy and policy on safety in clinical care. Further, a non-executive director should be given specific responsibility for …
Unknown
BRIS-110 — National Patient Safety Agency to manage national sentinel events database
Recommendation: The national database of sentinel events should be managed by the National Patient Safety Agency, so as to ensure that a high degree of confidence is placed in the system by the public.
Unknown
BRIS-106 — Establish independent National Patient Safety Agency for healthcare safety and quality
Recommendation: We support and endorse the broad framework of recommendations advocated in the report ‘An Organisation with a Memory’ by the Chief Medical Officer’s expert group on learning from adverse events in the NHS. The National Patient Safety Agency proposed as …
Unknown
IHRD-83 — SAI Deaths in Annual Reports
Recommendation: Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
Gov response: SAI-related death reporting incorporated into Trust annual reports.
Accepted
No update 2+ yrs
IHRD-82 — Policy on Learning from SAI Deaths
Recommendation: Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
Gov response: Trusts have published policies on responding to and learning from SAI-related deaths.
Accepted
IHRD-81 — Board Awareness of SAI Reports
Recommendation: Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
Gov response: Procedures established for ensuring Board members receive all SAI-related reports.
Accepted
IHRD-55 — Board Member Training on Patient Safety
Recommendation: Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.
Gov response: Training programmes implemented for Board members on scrutiny of patient safety performance.
Accepted
F144 — Need for ownership of quality metrics at a strategic level
Recommendation: The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of these through its regional offices, if appropriate.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F143 — Clear metrics on quality
Recommendation: Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression to poor performance can be identified and accepted as needing …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F141 — Taking responsibility for quality
Recommendation: Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its retained individual responsibility to take whatever action within its power …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
PFD Reports (145) — showing 50 strongest matches
Bertha Cray
Concerns: Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Response (Barts Health NHS Trust): The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been …
Responded
Kirabo Kiwanuka
Concerns: Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Overdue
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Overdue
Barry Dillion
Concerns: Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Overdue
Nellie Travis
Concerns: The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
Overdue
Stephen Ellis
Concerns: A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Overdue
Neil Carter
Concerns: There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Response (CQC): The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat …
Response (Priory Group): The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring …
Responded
Natasha Raghoo
Concerns: The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Response (Partnership in Care): Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC …
Overdue
Jean James
Concerns: Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Response (City Hospitals Sunderland): The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the …
Responded
John Adams
Concerns: VERONICA HAMILTON-DEELEY, LLB.
Overdue
Lana-Liza Chervonenko
Concerns: High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Overdue
Ronald Smith
Concerns: There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
Overdue
Anthony Geerts
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response (Brighton and Sussex University Hospitals NHS Trust): Brighton and Sussex University Hospitals NHS Trust has integrated the neck of femur service at the Princess Royal Hospital. They also recruited a new Clinical Nurse Practice Educator and implemented …
Overdue
Karen O’Brien
Concerns: The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Overdue
Mary James
Concerns: Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Overdue
Eileen Smith
Concerns: The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Response (Department of Health): The response acknowledges the concerns raised and references existing guidance and resources, including work by NHS England, NICE and the NPSA, but describes no specific actions taken or planned by …
Responded
Barry Pike
Concerns: The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.
Overdue
Sharon Henshall
Concerns: The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Overdue
Frederick Sutton
Concerns: Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.
Overdue
Rosalind Baird
Concerns: There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Overdue
Rebecca Jones
Concerns: Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.
Response (Department of Health): NHS England will spend £15m in 2016/17 to boost provision in areas that lack adequate health-based places of safety and is developing commissioning guidance for effective crisis response. HEE is …
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Darren Jones
Concerns: The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with the education of staff and availability of immunosuppressant drugs.
Overdue
Thelma Clarkson
Concerns: The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
Overdue
Stephen Adams
Concerns: Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.
Overdue
Bryan Catanach
Concerns: Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Overdue
Lincoln Brady
Concerns: Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): The Trust has implemented presentation scanning for women in labour, with a training and skills maintenance programme for midwives. The partogram will include a section for documenting scan results, and …
Responded
June Parkes
Concerns: Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.
Overdue
Alwyn Head
Concerns: Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Response (A head): The Trust introduced new admission/transfer documentation for patient infection status, is providing staff training, and implemented ward-to-board rounds. A Deteriorating Patient Programme and a Sepsis Action Group are in place, …
Responded
Dorothy Imisson
Concerns: The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Overdue
Milly Zemmel
Concerns: There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Response (Response Pennine Acute Hospitals): The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned …
Responded
Amanda Coulthard
Concerns: Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
Response: The Department of Health acknowledges concerns about nasogastric tube misplacement and refers to ongoing work, including an NIHR-funded project at the University of Hull to develop a location-indicating NGT.
Response (North Cumbria University Hospitals Trust): The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 …
Responded
Michael Parke
Concerns: Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
Response: The Department of Health acknowledges the need for consistent implementation of patient safety requirements for nasogastric tubes. They are considering the evidence and economic implications of routine pH testing and …
Response (North Cumbria University Hospitals Trust): The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 …
Responded
Kathleen Cooper
Concerns: A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS Trust, with errors and missed opportunities to treat the deceased, and poor communication between clinicians and nurses.
Overdue
Anna Walker
Concerns: Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in portering, ward nurse responsibilities, and unclear clinical accountability. The incident was also inappropriately downgraded.
Overdue
Annette Krasinsky-Lloyd
Concerns: Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Overdue
Caliel Smith-Kwami
Concerns: Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert clinicians to new results, hindering diagnosis before discharge.
Responded
Barry Tucker
Concerns: No specific concerns were detailed in the provided text.
Response (East Sussex Healthcare NHS Trust): The Trust will not accept bookings for major urology cancer surgery patients on the private patient unit. The urology specialty will conduct documentation audits to identify themes and improvements, and …
Responded
Frank Hayward
Concerns: Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, and significant CT scan delays.
Overdue
Lea Hunsley
Concerns: The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Response (EAM Care Group): EAM Care Group completed a root cause analysis with commissioners, will obtain post-operative care plans prior to admission, and introduced new handover procedures including lunchtime handovers and archiving of staff …
Responded
Marian Grant
Concerns: Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled with ineffective EPR alerts, increased the risk of avoidable death.
Responded
Hubert Kelly
Concerns: Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
Overdue
Rita Giles
Concerns: The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Overdue
Ronald Harman
Concerns: The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Overdue
John Waite
Concerns: Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a lack of national guidelines for this procedure.
Overdue
Angela Jackson
Concerns: A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and potentially delayed emergency treatment.
Overdue
Stephen Taylor
Concerns: Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
Responded
Mary Ryder
Concerns: Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.
Response (Department of Health Social Care): The Department of Health and Social Care (DHSC) consulted NICE, who advised that existing guidelines on VTE prophylaxis and management are adequate and do not require amendment.
Responded
Joseph Page
Concerns: Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Overdue
John Kirby
Concerns: Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.
Response (Sussex NHS Trust): Sussex Partnership NHS Foundation Trust has reduced the lead practitioner's caseload, implemented an information-sharing protocol between mental health liaison team and Pavillions A&E to improve communication, shared the ADHD NICE …
Overdue
Committee Recommendations (25)
#17 — Department fails to outline specific actions for reducing patient harm and improving safety.
Recommendation: The previous Committee were concerned that the Department was spending billions of pounds of taxpayers’ money without an effective plan to minimise future costs of the clinical negligence scheme.25 In April 2024, the Committee recommended that, by summer 2024, “the …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2026 4.2 The department and NHS England will continue to prioritise patient safety and a learning culture across the NHS so that harmful …
Not Addressed
#4 — Develop a plan to reduce patient harm and manage escalating clinical negligence costs.
Recommendation: It is unacceptable that the Department is yet to develop a plan to deal with the cost of clinical negligence claims, and so much taxpayers’ money is being spent on legal fees. The Department has set aside an astounding £58.2 …
Gov response: The government agrees with the Committee’s recommendation. the department and its partners is taking to reduce patient harm and improve patient safety in the NHS. NHS England is now in the final year of its …
Accepted
#15 — Lack of centralised learning causes repeated patient safety incidents across trusts.
Recommendation: Written evidence submitted to us raised concerns about a lack of centralised learning leading to incidents being repeated across multiple trusts.31 When asked what it was doing to improve systemic learning from patient safety incidents, NHS England told us it …
Gov response: 3. PAC conclusion: We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. 3a. PAC recommendation: The Department should establish …
Not Accepted
#13 — Health system overwhelmed by patient safety recommendations, hindering affirmative action.
Recommendation: In 2024, the Health Services Safety Investigations Body reported that the broader health system was drowning in patient safety recommendations rather than taking affirmative actions to improve it.26 NHS England told us that there are over 1,500 recommendations in the …
Gov response: 2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2e. PAC recommendation: The Department and NHS England should have a clear system of accountability for patient …
Accepted
#10 — Patient safety system suffers from duplication and minimal improvement amidst reforms.
Recommendation: The NHS reports around 2.4 million patient safety incidents annually, most of which (70%) cause no harm to patients, but around 0.5% of patient safety incidents result in severe harm or death. The 2025 Dash review identified considerable overlap and …
Gov response: 2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2a. PAC recommendation: The Department must set a national framework for improving patient safety with clear targets …
Accepted
#2 — Establish a national framework for patient safety with clear targets and improved complaints system.
Recommendation: The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing …
Gov response: The government disagrees with the Committee’s recommendation The wider question around the health economics of patient safety will be explored as part of the forthcoming update to the NHS Patient Safety Strategy by working with …
Accepted
#4 — Publish the Amos Review and outline concrete plans to reduce maternity care harm and costs.
Recommendation: The Department’s failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. Over the last 20 years the cost of settling claims involving infants and children has increased significantly. In 2024–25, costs for …
Gov response: The government agrees with the Committee’s recommendation. Maternity and Neonatal Investigation will publish its final report and national recommendations in June 2026. This investigation is independent of government. Prior to publishing a final report and …
Accepted
#73 —
Recommendation: Comprehensive analysis should be carried out to assess the safety of running the NHS with the limited latent capacity that it currently has, particularly in Intensive Care Units, critical care units and high dependency units.
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
#12 —
Recommendation: We again recommend that the Care Quality Commission includes consultation with patient groups and details of patient outcomes in its assessment of ICSs. (Paragraph 68) Funding and policies to tackle the backlog
Gov response: Accept in principle. The Government agrees that patient involvement in services is important, and that this should be taking place in all areas of health and care. The Care Quality Commission’s assessments of Integrated Care …
Under Consideration
#8 — High-value maternity brain injury claims drive significant clinical negligence costs.
Recommendation: NHS Resolution told us that clinical negligence is putting pressure on NHS budgets and is a significant cost to the public purse. The Department told us the reasons for the rising costs were complex. NHS Resolution explained that the increasing …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2026 The rising cost of clinical negligence and experience of patients navigating the system are of great concern to government and ministers are committed …
Response Pending
#4 —
Recommendation: We recommend that the CQC’s assessment of ICSs includes consultation with patient groups and consideration of patient outcomes, and that all relevant data is published.
No Published Response
#1 —
Recommendation: We support the proposals in the White Paper that will be included in the new Bill and welcome the direction of travel in the Government’s reform of health and social care. Provided that proper accountability mechanisms are put in place, …
No Published Response
#31 —
Recommendation: It is deeply concerning that maternity units appear to have been penalised for high Caesarean Section rates. We recommend an immediate end to the use of total Caesarean Section percentages as a metric for maternity services, and that this is …
Gov response: 130. We accept this recommendation. 131. NHSEI agrees that caesarean section rates should not be used to performance manage Trusts and supports the use of the Robson criteria to measure caesarean section rates more intelligently. …
Not Addressed
#23 —
Recommendation: England remains a largely safe place to give birth and efforts to increase the safety of maternity services have led to further improvements. However, the Expert Panel overall rated the Government’s progress on maternity safety outcomes as ‘Requires Improvement’. The …
Gov response: 106. The Government accepts this recommendation in part. 107. The NHS Mandate7 sets out an aim of year on year reductions in the difference in the stillbirth and neonatal mortality rate per 1,000 births between …
Not Addressed
#71 —
Recommendation: 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.
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
#71 —
Recommendation: 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.
Gov response: The government accepts this recommendation. NHS England is developing proposals for implementing surge capacity plans in the NHS, taking into account the lessons learned from the COVID-19 pandemic. These proposals will consider a range of …
Under Consideration
#6 — Set out how NHSE and NHS Supply Chain will involve clinicians in purchasing decisions.
Recommendation: NHSE and NHS Supply Chain have not convinced clinicians that they value the quality of products above price. We are concerned that a focus on costs may impact on the quality of outcomes for patients. We can see the value …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented NHS SC engages clinicians in all sourcing decisions. Lead trusts are used to ensure the voice of the clinical workforce is at the forefront of understanding …
Accepted
#2 — Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
Recommendation: In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in …
Gov response: Partially accept. The Department partially accepts this recommendation. We agree with the need to explore solutions to problems which constrain primary care, particularly given the high levels of demand and workforce pressures. However, we do …
Partially Accepted
#1 — General practice in crisis due to poor patient access and safety risks, unacknowledged by government.
Recommendation: The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has …
Gov response: Partially accept. The Department partially accepts this recommendation. We recognise that some people are facing challenges trying to access general practice services in a timely way, and general practice teams have been working immensely hard …
Partially Accepted
#35 —
Recommendation: In addition to the recommendations on data we set out in our report on the treatment of autistic people and people with learning disabilities, we further recommend that NHS England and Improvement regularly collect and publish high quality data including …
Gov response: We accept this recommendation. A single data set now collects all the information from both NHS and private sector services and is completed by all providers. It is able to analyse at a provider and …
Not Addressed
#34 —
Recommendation: It is vitally important to be able to monitor the experiences of children and young people in inpatient care, particularly how often restraint is used in each setting and whether there is appropriate access to advocacy. This is key to …
Gov response: We accept this recommendation. A single data set now collects all the information from both NHS and private sector services and is completed by all providers. It is able to analyse at a provider and …
Not Addressed
#11 —
Recommendation: Lastly, we heard that patient involvement in services was important to tackle long covid. It should also be taking place in other areas. We have previously called for the Care Quality Commission’s assessments of Integrated Care Systems (ICSs) to include …
Gov response: Accept in principle. The Government agrees that patient involvement in services is important, and that this should be taking place in all areas of health and care. The Care Quality Commission’s assessments of Integrated Care …
Under Consideration
#9 —
Recommendation: We recommend that NHS England undertake a review of the role of targets across the NHS which seeks to balance the operational grip they undoubtedly deliver to senior managers against the risks of inadvertently creating a culture which deprioritises care …
Gov response: 3.2 As a Government, we recognise that leaders and senior managers are central to creating a supportive, healthy and compassionate workplace culture. The NHS People Plan recognises that the most effective route to making change …
Under Consideration
#25 — Trusts primarily responsible for RAAC risk management, despite some national technical support.
Recommendation: We asked whether NHS trusts were getting adequate help from national bodies given the risks they had to manage. NHS England told use that it was helping trusts to source the right technical support, but trusts themselves were responsible for …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The NHS has been at the forefront of the public sector response to RAAC and has been surveying sites since 2019. The department will …
Not Addressed
#15 — Require the New Hospital Programme to conduct comprehensive live clinical testing of Hospital 2.0 designs.
Recommendation: Before the evidence session, we visited a “super hospital” project in Denmark. The Danes had built a prototype of a new operating theatre on the edge of an existing hospital and each surgical team was given access to it so …
Gov response: The government disagrees with the Committee’s recommendation. The government agrees that NHP should test Hospital 2.0, its standardised approach to building hospitals, and intends to do so at the earliest opportunity within one of the …
Not Accepted
CQC Inspection Actions (213) — showing 50 strongest matches
Chy Byghan Residential Home
The provider must ensure people are protected by systems or processes to assess, monitor and improve the quality of the services provided.
Must Do
Aspirations (Northampton)
Systems to manage and monitor the safety of the service and learning lessons from incidents were not consistently maintained nor robust enough to demonstrate the provider had the oversight they required to provide a consistently safe and effective service.
Must Do
Ash Court Care Centre - Camden
The registered person had not operated effective systems to: Assess, monitor and improve the quality of the service. Regulation 17 (2) (a) Assess, monitor and mitigate the risks relating to health, safety and welfare of service users. Regulation 17 (2) …
Must Do
Ambleside - Luton
The provider must have effective systems to assess and monitor the quality of the service, and to identify and manage risks.
Must Do
St Paul's Lodge
The registered person did not have suitable arrangements in place to regularly assess and monitor the quality of the services provided and to identify, assess and manage risks.
Must Do
Walfinch West Suffolk
The provider must ensure systems are in place and robust enough to demonstrate safety is effectively managed.
Must Do
Sobell Medical Centre
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Must Do
Sobell Medical Centre
Ensure care and treatment is provided in a safe way to patients.
Must Do
Smyth House
1.Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. 2.Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to— a.assess, monitor and improve the quality …
Must Do
Safe Sanctuary Living Ltd
Regulation 17 HSCA RA Regulations 2014 Good governance
Must Do
Oak Tree Lodge
Systems were not robust enough to demonstrate safety was effectively managed.
Must Do
Minstead Trust
The provider must ensure the effectiveness of the governance arrangements to operate effective systems and processes to assess and monitor the quality of the service and to identify and mitigate risks.
Must Do
Linden Road Surgery
Care and treatment must be provided in a safe way for service users
Must Do
Johnstons Homecare Ltd
The provider must ensure that systems are robust enough to demonstrate people's safety and quality of care are effectively managed.
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure good governance, including accurate record-keeping, effective audits, and appropriate monitoring of service quality.
Must Do
Foxleigh Grove Nursing Home
The provider must establish an effective system to enable them to ensure compliance with regulations 8 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Figtree Care Services Ltd
The provider and registered manager failed to ensure systems to monitor the quality and safety of the service were robust enough to identify areas that were in need of improvement.
Must Do
FarleyMed
Systems and processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards of care as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
East Cosham House
There was a failure to have effective and established systems and processes in place to monitor and improve the quality and safety of the service.
Must Do
Chesapeake House
There were ineffective systems and processes in place to enable the management team to monitor the service and drive improvements as required.
Must Do
Camphill Health Centre
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcare.
Must Do
BMI Southend Private Hospital
The provider must ensure that governance and risk management processes are effective in identifying risks.
Must Do
Ashington Gardens
Regulation 17 HSCA RA Regulations 2014 Good governance
Must Do
Ashington Gardens
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Must Do
10-12 Hainsworth Park
Regulation 17 HSCA RA Regulations 2014 Good governance
Must Do
10-12 Hainsworth Park
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Must Do
The Cottage Residential Home
The provider must implement systems to ensure people live in a service which is safe, effective, caring, responsive and well led.
Must Do
Stepping Out
Governance systems were not sufficiently robust to identify where quality and safety was being compromised.
Must Do
St.Theresa's Nursing Home
The provider must ensure that effective governance, including robust and effective quality assurance systems, consistent record-keeping for care needs, fluid intake, staff supervision, and accurate handover records, and that all required notifications to CQC are submitted.
Must Do
St Paul's Lodge
The registered person must establish and operate effective systems and processes to assess, monitor and improve the quality of the services provided and to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users …
Must Do
Serenity House
The provider had failed to ensure the safe careand treatment of people. Quality assurance systems were fragmented and ineffective. There was a lack of oversight of people's care, safety and the quality of service. Risk management process was not robust …
Must Do
Haisthorpe House
People who used the service were not protected against the risks of inappropriate or unsafe care and treatment, by means of the effective operation of systems and records, designed to enable the registered provider to regularly assess and monitor the …
Must Do
Gledhow Lodge
Management and leadership of the service was inadequate in ensuring there was effective oversight of the service. Governance systems were absent or ineffective in identifying areas of improvement and ensuring improvements were made.
Must Do
B&H Care Ltd
The provider must ensure effective systems are in place to assess, monitor and improve the quality of the service provided, identify and manage safety risks, and ensure people receive safe, effective, responsive and appropriate care, including maintaining accurate records, staff …
Must Do
Arthur House
The provider did not have robust and adequate systems in place to monitor the quality of the service.
Must Do
Bousfield Surgery
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcare.
Must Do
Billet Lane Medical Practice
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcareandtreatment.
Must Do
Aspen Lodge
We recommend that the provider reviews the systems in place to monitor and to help drive service improvements. Reviews of policies and procedures are required to ensure they remain up to date and are in line with best practice guidance.
Should Do
Woodlands
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Must Do
We Can Recover CIC
Leaders had not implemented safe systems and processes to provide safe and good quality care to clients using the service. Information was not available to us during the inspection and requested information from the previous two inspections remained outstanding. Policies, …
Must Do
We Can Recover CIC
Leaders did not have the skills, knowledge, and experience to perform their roles. Managers, including the new clinical lead, did not have experience in delivering a medically managed detoxification service. Managers had acted on some issues identified in the suspension …
Must Do
Taplow Manor
The service must ensure that there are effective and robust governance procedures in place to ensure that young people always receives safe care and treatment.
Must Do
Nower House
The failure to ensure consistent management oversight of the service and respond to shortfalls in a timely manner was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Kingsleigh Residential
The provider failed to operate effective systems to monitor the safety and quality of the service.
Must Do
Epilium & Skin
The service must ensure clinical governance processes are fit for purpose, contribute to the safer running of the service and enable the registered manager to gain assurance that risk and performance is managed effectively.
Must Do
Yanah Care
The provider must ensure effective systems and processes are in place to assess, monitor and improve the quality and safety of the services provided to people.
Must Do
Worcestershire Imaging Centre
The provider must ensure there is a robust governance system in place to ensure compliance with identifying a magnetic resonance expert and registered manager.
Must Do
Worcestershire Imaging Centre
The provider must ensure there is a robust governance system in place to ensure risks are identified and addressed.
Must Do
Woodbridge Lodge Residential Home
The governance systems in place were not robust enough to identify shortfalls and address them.
Must Do
Woodbridge Lodge Residential Home
The systems in place were not robust enough to reduce the risks of people receiving unsafe care.
Must Do
PHSO Ombudsman Recommendations (7)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Broken trust: making patient safety more than just a promise
The Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.
IMB Recommendations (13)
Springhill (2023)
Monitoring any new initiatives rolled out to enable the prison to better scrutinise the impact and quality of healthcare delivery and the health complaints system (6.1.3, 6.1.4 and 6.1.10).
Governor / Director
Wormwood Scrubs (2020)
Given the Board’s concerns relating to the provision of healthcare services, will the Governor ensure: (i) regular meetings of the strategic healthcare partnership? (ii) a fit-for-purpose healthcare complaints system, delivering timely and appropriate responses, with agreed deadlines? (iii) a significant reduction in the number of cancelled hospital appointments?
Governor / Director
Peterborough (Women) (2022)
Because of the widespread perception among prisoners that all Healthcare services (Clinical, Mental, and substance misuse) are not up to the standard expected, going forward the prison should prioritise the review and monitoring of Complaints to Healthcare e.g. in the Monthly Clinical Governance Meeting, to ensure that standards are maintained and improved.
Governor / Director
Gartree (2023)
Can the Prison Service confirm to the Board who has overall responsibility for the health and wellbeing of prisoners at Gartree?
HMPPS
Pentonville (2020)
Will you commit to giving Pentonville the funding it needs to install CCTV on those wings which still do not have it?
Other
Long Lartin (2020)
It is disappointing to report that measured safety, both for prisoners and staff, for the first eight months of the reporting year at the prison was poor.
Governor / Director
Hindley (2020)
Would the Prison Service support prioritising further improvements for the safety of prisoners at Hindley?
HMPPS
Stafford (2021)
Will HMPPS ensure that HMP Stafford and Practice Plus Group initiate, with immediate effect, a medicines management system that, unlike now, does not impair the safety of its residents and is put under close supervision until ALL previous recommendations (PPO, CQC, HMIP, etc.) have been fully and successfully delivered?
HMPPS
Lowdham Grange (2021)
Ensure that the best outcomes for prisoners (safety, fair and humane treatment, health and wellbeing, progression and release) are achieved in the new arrangements for operating the contract for HMP Lowdham Grange from February 2023.
HMPPS
Gartree (2021)
Can the Prison Service confirm to the Board who has overall responsibility for the health and wellbeing of the prisoners at Gartree?
HMPPS
Winchester (2022)
Would the minister agree that safety at Winchester is unsatisfactory and explain what other steps will be taken to ensure the recent positive trend is maintained?
Other
Swansea (2025)
How will the Governor ensure that the IMB has consistent access to meeting agendas and minutes from the health partnership forum?
Governor / Director
Littlehey (2024)
this should be subject to continual monitoring by the Governor.
Governor / Director
Health Investigations (16)
An independent review of the Independent Investigations for Mental Health … — Rec 8
It is recommended that the IIGC should develop measures to demonstrate the impact and outcomes of the Independent Investigation process, with particular regard to; learning, service improvement, policy development and the experience of all affected families and carers.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 7
It is recommended that the IIGC should develop additional metrics and key performance indicators to provide assurance of regional adherence to quality as well as process requirements of Independent Investigations and the Serious Incident Framework.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 6
It is recommended that the IIGC should alert the National Quality Board and the Quality Assurance Group of the complexities and challenges of sharing learning and implementing improvement across the wider systems and with those partners identified by recommendation four.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 4
It is recommended that the IIGC continues to function as the strategic governance group for Independent Investigations into mental healthcare related homicides, and makes the necessary linkages with other national programmes of work i.e. mental health and quality and safety.
north_east_yorkshire
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1c
Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group to enable early identification of risk and timely intervention.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1b
A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly to provide a single, coordinated mechanism for monitoring and acting …
wales
Accepted
An independent review of the Independent Investigations for Mental Health … — Rec 9
It is recommended that the outcomes of the perpetrator characteristics and profile identified in this review be shared with the appropriate commissioners and service providers for the future commissioning of services.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 5
It is recommended that the IIGC identifies the strategic co-dependencies with agencies such as police, probation, prison engaged with mental health services to optimize the learning and improvement and to provide a platform for joint working at the strategic level.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 3
It is recommended that the requirement for consideration of predictability and preventability in IIMHH investigations is either removed or a national standard definition provided and used by all Investigation panels and included in the revision and the principles of the Serious Incident Framework.
north_east_yorkshire
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1d
A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bii
The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that its membership is expanded to include educators, researchers and student …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bi
We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on the national strategic oversight Board.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1a
The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, and provide strengthened clinical oversight and accountability of Health Boards …
wales
Accepted
An independent review of the Independent Investigations for Mental Health … — Rec 2
It is recommended that a national repository is provided to deliver a single access point for IIMHH reports, and that publication standards are developed to provide complete publication of the IIMHH, the synopsis and the recommendations for public access
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 1
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality of reports; including standardised template and agreed investigation methodology II. …
north_east_yorkshire
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 2b
All maternity, neonatal and relevant education providers to actively progress through the stages of UNICEF UK Baby Friendly Initiative accreditation.
wales
Accepted
Article 2 Learning Points (5)
— LP 6
We recommend that this should be a stipulation in the membership of all case review panels and that the Governor should establish that this is now observed at HMP Swansea.
HMPPS
Accepted
— LP 3
We recommend that the Governor of HMP Swansea is asked to establish that appropriate arrangements are in place.
HMPPS
Accepted
— LP 1
We recommend that the Governor of HMP Swansea is asked to establish that robust measures are now in place to ensure that these breaches no longer happen.
HMPPS
Accepted
— LP 2
I recommend that NHS England and NOMS: take note of the findings in Chapter 11, and consider jointly in the light of this investigation whether the lessons of this investigation have a wider application; in particular, that they consider whether they are satisfied that adequate arrangements are now in place …
NHS England, NOMS
— LP 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and …
HMP Lincoln, HMP Ranby
PHSO Casework Decisions (20)
P-004714 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains while his father, Mr S, was in University Hospitals Birmingham NHS Foundation Trust (the Trust), he was sexually assaulted by another patient while the staff knew the patient posed a risk. He also complains in the Trust response, it supplied false and misleading information.
NHS in England
Jan 2026
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-003414 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust did not appropriately monitor her brother, Mr Z, when he was undergoing Trial Without Catheter (TWOC), and did not respond adequately when he developed a life-threatening complication.
NHS in England
Mar 2025
P-004314 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs A complains about the care provided to her husband, Mr B, by Lancashire Teaching Hospitals NHS Foundation Trust (the Trust) when he was in hospital between 23 February and 10 March 2022.
NHS in England
Upheld
Nov 2025
P-004424 — Barts Health NHS Trust
Miss B complains the Trust failed to prevent an assault that took place on her father whilst in ED.
NHS in England
Nov 2025
P-001449 — Wye Valley NHS Trust
Ms A complained about the care and treatment she received for an injury to her knee at the Wye Valley NHS Trust.
NHS in England
Jul 2022
P-001587 — Stockport NHS Foundation Trust
Mrs A complains that the Trust did not complete her kidney stent replacement surgery correctly.
NHS in England
Aug 2022
P-001488 — University Hospitals Bristol and Weston NHS Foundation Trust
Mrs R complains about the experience her brother had during an inpatient stay at the Trust in May 2021.
NHS in England
Aug 2022
P-001539 — North Bristol NHS Trust
Ms A complains about care and treatment she received from the Trust in 2018.
NHS in England
Sep 2022
P-003305 — Manchester University NHS Foundation Trust
Mrs E complains that staff allowed her husband to go to the bathroom alone and without oxygen which resulted in him having a fall.
NHS in England
Jan 2025
P-003348 — Kettering General Hospital NHS Foundation Trust
Miss G complains that in October 2023 the Trust caused a deep tissue burn to her baby son by not correctly monitoring a foot monitor that had been placed on him to check his oxygen and heart rate.
NHS in England
Feb 2025
P-004130 — A practice in the Oldham area
Mrs B complains that on 10 and 24 October 2022, the Trust did not take steps to protect her sister from infection when she needed investigations. She says she was undergoing chemotherapy for acute myeloid leukaemia and was at high risk of infection.
NHS in England
Partly Upheld
Oct 2025
P-004487 — University Hospitals Sussex NHS Foundation Trust
Mr Y has concerns that his mother experienced a fall at the Trust and subsequently died. Mr Y was also concerned about the Patient Safety Incident Investigation
NHS in England
Dec 2025
P-001237 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mr O complained about a fall his wife had while being assisted at the Trust.
NHS in England
Dec 2021
P-001957 — Croydon Health Services NHS Trust
Mr G complains about the Trust's decision to stop treating his sister with antibiotics for an infection.
NHS in England
Apr 2023
P-003854 — A dental practice in the Bromley area
Mr E complains that after his hygienist appointment in October 2022, his wisdom tooth cracked and exposed a hole. He complains about the Practice's advice and how it managed his problem.
NHS in England
Jul 2023
P-003899 — A dental practice in the Lambeth area
Mr I complains the Practice removed his upper right sixth tooth and did not replace it with a dental bridge.
NHS in England
Aug 2023
P-002833 — Homerton Healthcare NHS Foundation Trust
Ms E complains about the care and treatment she received at Homerton Healthcare NHS Foundation Trust when she had spinal surgery.
NHS in England
Aug 2024
P-002940 — Barts Health NHS Trust
Mr H complains the Trust did not carry out the operation to remove his tonsils correctly because they were only partly removed.
NHS in England
Sep 2024
P-004367 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs D complains whilst she was giving birth, the obstetrician continued despite struggling to use forceps, then failed to properly stitch her episiotomy or check for placental remains. She complains once her daughter was born, she was left unattended in a neonatal cot and her facial wound was not cleaned …
NHS in England
Nov 2025
LGO / SPSO Decisions (444)
NIPSO-18869 — Northern Health and Social Care Trust
An investigation by the Public Services Ombudsman has found that the Northern Health and Social Care Trust did not properly monitor a patient’s food and drink intake during her stay in the Antrim Area Hospital.
NIPSO (NI Public Service…
Health & Social Care
Jun 2020
NIPSO-19704 — South Eastern Health and Social Care Trust
The Ombudsman recommended that a patient be given an apology after an investigation found he did not receive the fundamental standards of care while being treated in hospital. Failures included the lack of records relating to the decision to admit him to an escalation bed, and a failure to record …
NIPSO (NI Public Service…
Health & Social Care
Jul 2020
NIPSO-17125 — Northern Health and Social Care Trust
The Ombudsman has made a recommendation to the Northern Health and Social Care Trust to reduce the risk of a delay in the communication of results to patients, and to patients receiving results in unplanned circumstances, following an investigation into the care of a man with terminal lung cancer.
NIPSO (NI Public Service…
Health & Social Care
Jul 2020
NIPSO-17919 — Homecare Independent Living
We recommended that a healthcare provider review its policies and improve staff training after we investigated the care it provided to a complainant’s elderly mother.
NIPSO (NI Public Service…
Health & Social Care
Oct 2020
NIPSO-16741 — Belfast Health and Social Care Trust
Our investigation into a complaint about the care and treatment of a cancer patient has led to an apology to the complainant and a review of the issue of pain management on two wards in the Mater and Royal Victoria hospitals.
NIPSO (NI Public Service…
Health & Social Care
Jan 2021
NIPSO-202001078 — Department of Health
We investigated a complaint from a member of the public who believed she was treated unfairly by the Department of Health.
NIPSO (NI Public Service…
Central Government
Upheld
Jun 2023
NIPSO-201912205 — Southern Health and Social Care Trust
We found failures in the care provided by the Southern Trust to an elderly woman and her daughter.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2023
NIPSO-202000522 — Belfast Health and Social Care Trust
A man whose son lived in supported housing complained about the care provided by the Belfast Trust. We upheld his complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2023
NIPSO-202002717 — Belfast Health and Social Care Trust
A woman complained about the care her elderly mother received over a 10 day period in the Mater Hospital. We upheld parts of the complaint, including over how the hospital dealt with an incident in which the patient was in an agitated state, and the way it managed her food …
NIPSO (NI Public Service…
Health & Social Care
Upheld
Dec 2023
NIPSO-care-and-treatment-patient-antrim-area-hospital-0 — Northern Health and Social Care Trust
A woman complained that the Northern Trust should have consulted her and her family when making decisions around the care of her late mother. We found the Trust's decision making at the time was appropriate, but were critical of the way it dealt with her complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
PSOW-202500244 — Aneurin Bevan University Health Board
Mr X complained that Aneurin Bevan University Health Board had failed to respond to his complaint. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr Xs complaint. She said this caused inconvenience and frustration for Mr X. The Ombudsman decided to …
PSOW (Public Services Om…
Health
May 2025
22-003-453b — Mersey Care NHS Foundation Trust (FT) (22 003 …
Summary: We found fault by a Council and ICB as they failed to provide Mrs R with care and support to meet her assessed needs. The Council and ICB will apologise to Mrs R’s son, Mr P, and pay him a financial remedy in recognition of the distress this caused …
LGO (Local Government & …
Health
Not Upheld
Dec 2022
22-017-440a — Royal United Hospitals Bath NHS Foundation Trust (22 …
Summary: We uphold Miss Y’s complaint about her father’s hospital discharge and care. We found fault with the way Mr X was discharged from hospital, the care he received in a care home and some aspects of his hospital inpatient care. As a result, Mr X did not receive the …
LGO (Local Government & …
Health
Upheld
May 2024
24-021-087a — South West London & St. Georges Mental Health …
Summary: Mr A has complained about a lack of aftercare planning by a Council, Integrated Care Board and a Mental Health Trust for his daughter, Miss B. Mr A said this led to deterioration in her mental health. We found fault with these organisations who have agreed to carry out …
LGO (Local Government & …
Health
Upheld
Nov 2025
NIPSO-18957 — Belfast Health and Social Care Trust
The patient complained that he should have had a scan and been assessed for surgery on his groin, about the attitude of the consultant who saw him, and that he was discharged from the hospital without any pain relief.
NIPSO (NI Public Service…
Health & Social Care
Jun 2020
NIPSO-16347 — Belfast Health and Social Care Trust
A complainant who believed that her mother was not fit to be discharged from hospital, and who said she should not have been sent home without medication, has had part of her complaint about the Belfast Health and Social Care Trust upheld.
NIPSO (NI Public Service…
Health & Social Care
Oct 2020
NIPSO-16347 — Belfast Health and Social Care Trust
We upheld parts of a complaint about the management of the patient's pain relief, the hospital's communication with her family, the supply of her medication, and the decision to discharge her.
NIPSO (NI Public Service…
Health & Social Care
Dec 2020
NIPSO-201915832 — Western Health and Social Care Trust
We found that the Trust failed to follow any multidisciplinary assessments when it assessed a patient for Continuing Healthcare.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-20700 — Belfast Health and Social Care Trust
We found that the Belfast Health and Social Care Trust did not provide a patient with a multi-disciplinary review prior to her discharge from the Royal Victoria Hospital.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-18735 — Belfast Health and Social Care Trust
We have asked the Belfast Health and Social Care Trust, in consultation with the other Trusts and health and social care organisations, to agree a uniform approach for assessing all future applications for Continuing Healthcare in Northern Ireland.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-19010 — South Eastern Health and Social Care Trust
We found that the South Eastern Health and Social Care Trust dealt with a complainant’s concerns fairly, but were critical of the time it took to address them.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-202000673 — Woodbrooke Medical Practice
Our investigation found that the GP Practice properly managed the patient’s medication, and that it made appropriate referrals for further testing.
NIPSO (NI Public Service…
Health & Social Care
Mar 2023
NIPSO-202000636 — Southern Health and Social Care Trust
We found that the care provided by Craigavon Area Hospital to a woman and her new born baby was appropriate, but upheld the complaint that they were discharged prematurely.
NIPSO (NI Public Service…
Health & Social Care
May 2023
NIPSO-202000037 — Southern Health and Social Care Trust
A man said that his partner could have avoided emergency surgery had she received better treatment from the Southern Health and Social Care Trust. We did not uphold the complaint.
NIPSO (NI Public Service…
Health & Social Care
May 2023
NIPSO-improving-healthcare-through-better-patient-engagement — Various
Shared decision making in a healthcare setting is about involving patients and their families in decisions about their clinical care. Not only does this foster a more compassionate, effective healthcare service, it is vital for patient safety. By listening to and working with patients, a service is more likely to …
NIPSO (NI Public Service…
Health & Social Care
Sep 2024
NIPSO-202003738 — Belfast Health and Social Care Trust
A woman complained about the care provided by the Belfast Health and Social Care Trust to her late father in his final weeks. We upheld parts of the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jan 2025
NIPSO-202002627 — Northern Health and Social Care Trust
The Northern Trust failed to act on a woman’s concerns about her mother’s health. This, as well as its failure to properly assess her spinal injury and accurately read the results of an MRI scan, led to her untimely death.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
NIPSO-202005529 — Northern Health and Social Care Trust
A woman complained that failures in her husband’s care while he was in hospital contributed to a deterioration in his health. We partially upheld the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
May 2025
NIPSO-202400522 — Northern Health and Social Care Trust
The Northern Trust failed to develop an appropriate plan for managing a patient’s incontinence during his stay in Causeway Hospital.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Oct 2025
PSOW-202005689 — Aneurin Bevan University Health Board
Mr X complained to the Ombudsman about the care that Aneurin Bevan University Health Board (the Health Board) had provided to his late son. Mr X had complained to the Health Board in May 2020 and received a response in October 2020. However, in making his complaint to the Ombudsman, …
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202005955 — Aneurin Bevan University Health Board
Mr X complained that the Health Board had not responded to his complaint about his late wife’s care and treatment made in May 2020. The assessment found that the response was outstanding. In order to resolve the complaint, the Health Board agreed to issue an appropriate response and it did …
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202005973 — A GP Practice in the area of Hywel …
Lack of GP complaint response
PSOW (Public Services Om…
Health
Apr 2021
PSOW-201907352 — Swansea Bay University Health Board
Ms A complained about the treatment and care received by her late uncle, Mr B, during his stay on Dan Danino Ward (the Ward) at Morriston Hospital (the First Hospital) between 6 March and 3 July 2019. In particular, she complained that Swansea Bay University Health Board (the Health Board) …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202000225 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board (the Health Board) failed to treat her mother (Mrs Y) in a timely manner and within the NHS Wales, Rules for Managing Referral to Treatment Waiting Times (RTT targets). Mrs Y had an endometrial carcinoma (a form of cancer affecting the …
PSOW (Public Services Om…
Health
Not Upheld
Apr 2021
PSOW-202001107 — Aneurin Bevan University Health Board
Mrs A complained about the treatment she received from Aneurin Bevan University Health Board between February 2019 and March 2020. Specifically, Mrs A complained that a specialist scan did not identify a tumour in her uterus. She was unhappy that treatment options, including a possible hysterectomy, were not fully considered …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202001144 — Cardiff and Vale University Health Board
Ms D complained about the treatment she received at the Emergency Department (the ED) of the University Hospital of Wales (the UHW) when clinicians misdiagnosed an injury that she sustained to her left ankle following a fall. Ms D complained that, after reviewing an X-ray, an Emergency Nurse Practitioner (an …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202001850 — A GP Practice in the area of Aneurin …
Mrs B complained about the care and treatment provided to her husband, Mr B, by a GP Practice in the area of the Aneurin Bevan University Health Board (the Practice). She complained that when her husband, Mr B, attended the Practice with symptoms and a family history of diabetes, the …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202004183 — Aneurin Bevan University Health Board
Mrs A complained about the care given to her late mother, Mrs B, who developed urosepsis while under the care of Aneurin Bevan University Health Board (the Health Board). Whilst the Health Board accepted that there was a significant failing of care, meriting redress under the relevant complaint handling regulations, …
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202005308 — A GP Practice in the area of Cardiff …
Complained that Practice did not diagnose or refer pt in a timely manner for investigation of abdominal issues – the pt was eventually found to have advanced (colorectal) cancer and sadly died.
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202000416 — Betsi Cadwaladr University Health Board
Mr B complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to diagnose bowel cancel during multiple emergency hospital admissions from August to November 2019. He felt particularly that the Consultant who was mainly in charge of his treatment after his final admission in November should have diagnosed …
PSOW (Public Services Om…
Health
Not Upheld
May 2021
PSOW-202101308 — Cwm Taf Morgannwg University Health Board
Miss X complained that the Health Board had delayed treating her daughter’s injured foot for 3 days. She said the reasons provided to her at the time were untrue and that the delay had caused further suffering and distress for her daughter. In considering the complaint, the Ombudsman noted that …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-201907531 — Hywel Dda University Health Board
Ms M complained on behalf of her friend, Ms A, about the care that Ms A received from the GP Practice and the nurse practitioner in August 2017. The GP had also failed to review Ms A’s anti-psychotic medication. In relation to the Health Board, Ms M’s concerns centred on …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
PSOW-202101445 — Aneurin Bevan University Health Board
Mrs X complained that the Health Board had not provided a response to her complaint submitted to it in December 2020, despite five holding letters being issued. The Ombudsman was concerned by the lack of response. The Health Board agreed to provide Mrs X with a full written response to …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-202001962 — Betsi Cadwaladr University Health Board
Mr B complained that, from 2017, the Health Board failed to conduct appropriate assessments and make suitable referrals following his request to be referred to the Gender Identity Clinic. He also complained about the standard of communication about progress on his request, and said that the Health Board failed to …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
PSOW-202002601 — Betsi Cadwaladr University Health Board
Mrs A underwent a colonoscopy on 12 March 2020 at Ysbyty Gwynedd. She complained that a perforation in her bowel was not identified before she was discharged. Mrs A said that during the procedure her reports of discomfort were not acknowledged and that she was not adequately monitored during recovery. …
PSOW (Public Services Om…
Health
Not Upheld
Jun 2021
PSOW-202001388 — Betsi Cadwaladr University Health Board
Mrs G complained that, as a result of failings in the end-of-life care that her late husband, Mr G, received at Ysbyty Glan Clwyd, his deterioration and death from pneumonia and sepsis was acutely painful and distressing. Mrs G complained that, for the last 2 days of his life, clinicians …
PSOW (Public Services Om…
Health
Upheld
Jul 2021
PSOW-202100430 — Cwm Taf Morgannwg University Health Board
Ms J complained that her father, Mr T, was inappropriately discharged from hospital without having seen a kidney specialist and without full investigations having been carried out, that there were failings in the care and treatment provided to Mr T during a second admission, and that the reasons for his …
PSOW (Public Services Om…
Health
Upheld
Apr 2022
PSOW-202100471 — Betsi Cadwaladr University Health Board
Miss K complained about the care and treatment her mother, Mrs L, received following her admission to Ysbyty Glan Clwyd on 18 June 2020. In particular, Miss K was unhappy about the failure to diagnose Mrs L with cirrhosis of the liver, the failure to treat appropriately and determine whether …
PSOW (Public Services Om…
Health
Upheld
Apr 2022
PSOW-202101075 — Hywel Dda University Health Board
On 27 January 2020 Mrs X was admitted at Withybush General Hospital with a heaviness in her chest, and she was diagnosed with an unstable angina. Two days later Mrs X was seen by a consultant cardiologist who noted her chest pain was relieved by nitrates. Mrs X was transferred …
PSOW (Public Services Om…
Health
Not Upheld
May 2022
PSOW-202105485 — Powys Teaching Health Board
Mrs X complained about the care provided to her husband Mr X, by an English NHS Trust (“the Trust”). The Ombudsman was satisfied that the Health Board had a legal responsibility for Mr X’s care as a resident of Powys who was registered with a GP in Powys. Taking into …
PSOW (Public Services Om…
Health
May 2022