Poor health and social care integration
Lack of a fundamental shift towards collaborative, integrated system-wide change in health and social care.
1,185 items
15 sources
10 inquiries
Source spread
Where this theme appears
Poor health and social care integration has been flagged across 15 independent accountability sources:
24 inquiry recs
160 PFD reports
321 committee recs
3 CQC actions
2 HMICFRS recs
9 PPO recs
4 IOPC recs
27 NAO recs
1 PHSO rec
122 IMB recs
10 Article 2 learning points
11 detention investigation recs
97 PHSO decisions
390 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 (24)
IHRD-49 — Multi-Trust Mortality Meeting Engagement
Recommendation: Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with …
Gov response: Video conferencing facilities provided for multi-Trust mortality meetings.
Accepted
F235 — Joint proceedings
Recommendation: The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising …
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
F234 — Cooperation with the Care Quality Commission
Recommendation: Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to minimise the time taken to resolve issues and maximise the …
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
SP53 — GMMH and Alder Hey joint SMART audit
Recommendation: At the local level, Greater Manchester Mental Health NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust should by no later than 13 October 2026 carry out and report on a joint audit to ensure that for cases involving …
Response Pending
SP51 — GMMH local structured risk assessment responsibility
Recommendation: At the local level, Greater Manchester Mental Health NHS Foundation Trust should liaise with all of the relevant community healthcare organisations (including Child and Adolescent Mental Health Services and Criminal Justice Liaison Services) to ensure that there is clarity about …
Response Pending
BRIS-67 — Focus NHS leadership investment on joint, multi-professional training for all staff
Recommendation: The NHS’s investment in developing and funding programmes in leadership skills should be focused on supporting joint education and multi-professional training, open to nurses, doctors, managers and other healthcare professionals.
Unknown
BRIS-64 — Create shadowing opportunities for managers and clinicians to understand roles
Recommendation: Greater opportunities should be created for managers and clinicians to ‘shadow’ one another for short periods to learn about their respective roles and work pressures.
Unknown
BRIS-62 — Increase opportunities for multi-professional teams to learn and train together
Recommendation: There should be more opportunities than at present for multi-professional teams to learn, train and develop together.
Unknown
BRIS-61 — Implement joint inter-professional courses in healthcare professional education and training
Recommendation: The education, training and Continuing Professional Development (CPD) of all healthcare professionals should include joint courses between the professions.
Unknown
F237 — Teamwork
Recommendation: There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance staff, and catering staff also needs to be recognised 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
10 — Establish partner Trust buddying arrangement
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff development and sharing approaches to problems. This arrangement is promoted …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
IBI-4e — Cross-Administration Patient Safety Coordination
Recommendation: Coordination of patient records with devolved governments: Consideration should be given by the national healthcare administrations in England, Scotland, Wales and Northern Ireland, to further coordination of their approaches particularly to ensure that patterns of harm, or trends, are identified …
Gov response: NHS England operates the Learn From Patient Safety Events service, analysing approximately 3 million incidents annually. Scotland requires Health Boards to notify Healthcare Improvement Scotland of significant adverse events. Coordination mechanisms continue developing across the …
Accepted
No update 2+ yrs
IBI-10a(iv) — Thalassaemia Society Support
Recommendation: Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
Gov response: UK Government NHS England has successfully established a comprehensive programme of work to prioritise reduction of clinical risk, increase support and care in the community, digitise care plans and step up prevention activities following their …
Accepted in Part
No update 2+ yrs
IBI-9d — Haemophilia Centre Resources
Recommendation: The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they …
Gov response: UK Government Recommendation 9d: The need to develop and strengthen multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders to improve patient care and support standardisation is supported by …
Accepted
No update 2+ yrs
HIA-8 — Specialist Care and Assistance Facilities
Recommendation: Sufficient funds should be made available by government on a ring-fenced basis for a fixed period of ten years, subject to a review after five years, to establish dedicated specialist facilities in Belfast, Derry and, if necessary, at other suitable …
Gov response: No formal government response published.
Accepted
No update 2+ yrs
LAMI-6 — Establish a Committee for Children and Families to coordinate inter-agency services
Recommendation: Each local authority with social services responsibilities must establish a Committee of Members for Children and Families with lay members drawn from the management committees of each of the key services. This Committee must ensure the services to children and …
Unknown
BRIS-177 — NSF must provide strategic guidance for integrating children's healthcare services
Recommendation: There must be much greater integration of primary, community, acute and specialist healthcare for children. The NSF should include strategic guidance to health authorities and trusts so that services in the future are better integrated and organised around the needs …
Unknown
BRIS-32 — Promote collaboration among patient advocacy services for seamless information and support
Recommendation: So as to provide for patients an effective, efficient and seamless information and advocacy service, consideration should be given to how the various patient advocacy and liaison services in a given geographical area could most effectively collaborate, including in relation …
Unknown
BRIS-22 — Fund voluntary organisations meeting NHS standards for patient and carer support
Recommendation: Voluntary organisations which provide care and support to patients and carers in the NHS (such as through telephone helplines, the provision of information and the organisation of self-help groups) play a very important role. Groups which meet the appropriate standards …
Unknown
R19 — ICN instructions recorded
Recommendation: Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Gov response: Section 4.2 of the Scottish Government's response details the professional standards for record-keeping for nurses and doctors. The revised NMC code requires nurses and midwives to complete all records at the time or as soon …
Accepted
IR2-16 — Central Delivery with Devolved Support
Recommendation: I recommend that the compensation scheme should be delivered by one central body, appropriately resourced and staffed. Current support schemes should however continue to be provided as at present by schemes local to each nation.
Gov response: In line with recommendations 14 and 16 of the Second Interim Report, IBCA has been established to deliver the Infected Blood Compensation Scheme and financial compensation to victims of infected blood on a UK-wide basis. …
Accepted
HIA-3 — Commissioner for Survivors of Institutional Childhood Abuse (COSICA)
Recommendation: We therefore recommend that a designated person should act as an advocate for such children, and should be responsible for ensuring the co-ordination and availability of services, and identifying suitable means whereby such services can be made available to those …
Gov response: No formal government response published.
Accepted
BRIS-3 — Adopt patient-professional partnership model across all NHS healthcare settings
Recommendation: The notion of partnership between the healthcare professional and the patient, whereby the patient and the professional meet as equals with different expertise, must be adopted by healthcare professionals in all parts of the NHS, including healthcare professionals in hospitals.
Unknown
RHI-37 — Reduce Organisational Silos
Recommendation: In keeping with the spirit of the Ministerial Pledge of Office, the Northern Ireland political parties, supported by the Northern Ireland Civil Service, should together agree a set of actions to reduce organisational silos arising between the government Departments and …
Gov response: [Note: The NI Executive responded to recommendations 5-7, 25, 37, 39-43 together as a group under the 'Ministers and Special Advisers' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full, with …
Accepted
No update 2+ yrs
PFD Reports (160) — showing 50 strongest matches
Karen Sutton
Concerns: Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication policy.
Response (University Hospitals of Leicester): The Medical Director reminded consultants of their duty to contact specialist teams for patients with complex needs, and the hospital expects to have software by April 2014 to alert consultants …
Responded
Rose Jean Coles
Concerns: Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
Response (University Hospital Bristol): University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Responded
Michael Longley
Concerns: Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
Overdue
Leslie Pates
Concerns: A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and no pressure-relieving mattress.
Response (Tamside Hospital NHS): Tameside Hospital NHS describes several actions taken to improve communication regarding discharge plans, including developing a checklist, ensuring documented evidence of discussions with patients and carers, raising the profile of …
Overdue
Peter Galea
Concerns: Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting patients to a place of safety for detailed assessment.
Overdue
Lorna Cullen
Concerns: The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
Overdue
Jamie Barlow
Concerns: There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.
Overdue
Stephen Church
Concerns: A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed a Mental Health Act assessment for a high-risk individual.
Response (Thames Valley Police): Thames Valley Police is coordinating the re-drafting of an interagency joint working protocol for managing mental health in the Thames Valley area, taking into account the findings of the inquest.
Response (British Transport Police): BTP updated its Manual of Guidance to ensure detainees are not left unsupervised until formally handed over to medical professionals, and that relevant mental health professionals are advised of the …
Response (Royal Berkshire NHS Trust1): The Trust has finalised an interagency protocol and will be sending it out to all the agencies involved for consultation and will discuss the revised protocol with training for staff …
Responded
Neophytos Constantinou
Concerns: Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.
Overdue
Pauline Taylor
Concerns: Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.
Response (Department of Health): The Department of Health acknowledges the concerns, notes BAUS's definition of nephroureterectomy, and states that decisions on clinical team operations are for the local Trust to address, also suggesting the …
Response (Leeds Teaching Hospital): The hospital clarified that "nephroureterectomy" means removal of the kidney with the whole ureter, emphasized this guidance to staff and included it in induction information. They filled Clinical Nurse Specialist …
Responded
Louise Henry
Concerns: A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was responsible for the patient's ongoing care.
Response (Derbyshire Healthcare NHS Trust): Derbyshire County Council will rebrand its recovery team as "Fieldwork (Mental Health)" and launch this at the next Social Care Forum. Derbyshire Healthcare NHS Foundation Trust is undergoing a transformation …
Response (NHS England): NHS England recommends practices review their Serious Mental Illness registers to ensure appropriate patients have information shared with Out of Hours providers. The Medical Interoperability Gateway has been introduced in …
Responded
Shannon Gee
Concerns: Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.
Overdue
George Taylor
Concerns: A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.
Response (Department of Health): The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. …
Responded
Andrew Frost
Concerns: A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on crisis team service limitations.
Response (Killick Street Health Centre): The health centre met with the Crisis Team to discuss service provision and will hold meetings every 6 months to discuss the Crisis Team service and individual clients.
Responded
Robert Yarnell
Concerns: After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient attempts to contact him or his family, and care was not effectively transferred to the Trafford Crisis Resolution Home Treatment Team.
Overdue
Alexander Ball
Concerns: Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, resulted in inadequate care coordination for complex patients.
Response (Greater Manchester West NHS Trust): Unity is actively involved in the Cumbria wide Crisis Care Concordat working group and members of the Frequent Attenders meetings. They are actively working with partners to provide a joined …
Response (Cumbria Partnership): The Trust is implementing actions by the end of April 2015, including development of a communications protocol and directory, and a review of referral processes. Measures to address waiting times …
Responded
Andrew Nickolls
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Overdue
Meryl Parry
Concerns: A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not have appropriate safety and welfare arrangements in place.
Response (Greenlane Care Homes Limited): Greenlane Care Homes Limited confirms their Discharge Pack has been changed to include the procedure to follow for an unanticipated discharge.
Overdue
Alun Walters
Concerns: The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.
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
Samantha Beach
Concerns: The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community midwives, GPs, and the obstetric department, and the obstetric department was not involved when the patient attended the Emergency Department post-natally.
Overdue
Margaret Ferry
Concerns: The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.
Response: A new standing operational procedure has been developed to provide a comprehensive approach to inter-organisational referrals for plastic surgery opinions; it ensures that the referral is clearly documented, a suitable …
Responded
Barry Thraves
Concerns: Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.
Response: Adult Social Care will send letters to individuals waiting for assessments from an Adult Mental Health Team, explaining Adult Social Care's role and how to contact the team if the …
Response: The LPT will review and update its DNA policy by March 2016; CMHTs are undergoing service redesign to remove internal barriers between the Outpatients Service and the wider CMHT, including …
Responded
Charlotte Bevan and Zaani Malbrouck
Concerns: There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Response: A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and …
Responded
Jacqueline Williams
Concerns: The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental Health Liaison Team also lacked a process to identify patients awaiting assessment.
Response (Lancashire Care NHS Trust): • All staff were briefed on the referral process to ensure full understanding, and learning from the joint investigation was shared. • The Trust met with East Lancashire Teaching Hospitals …
Responded
Colin Williams
Concerns: A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Overdue
Louise Locke
Concerns: Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.
Response (Southern Health NHS Foundation Trust): The Adult Mental Health Management Team has assigned an action to Clinical Service Directors to formulate a standard plan to ensure that patients requesting second opinions have access to these …
Responded
Isla Lord
Concerns: A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.
Response (I lord): The Standard Operating Policy for obstetric ultrasound scanning has been amended to include consultant requests for detailed delivery plans from tertiary centers, documented in patient notes. This policy has been …
Responded
Philip Denning
Concerns: Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of available help pose significant risks.
Overdue
Leslie Morrison
Concerns: No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Response (MORRISON Leslie): The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also …
Overdue
Winston Harris
Concerns: The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not consider an emergency DOLS despite his dementia and previous attempts to leave; the DOLS application was not processed before his death.
Responded
Patrick Steer
Concerns: Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.
Response (Wrightington Wigan and Leigh NHS Trust): Response could not be classified due to illegible document.
Responded
Christopher MacMorland
Concerns: Despite being under the care of gastroenterologists, the patient was not treated in a specialist gastroenterology ward despite multiple requests, and consultant requests for patient transfer to specialist wards are commonly not implemented.
Response (Portsmouth Hospitals NHS Trust): The Trust implemented a 'buddy' ward system where patients of certain specialties are cohorted only into the appropriate specialist ward or specific buddy ward.
Responded
Grant Burns
Concerns: There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.
Response (Solent NHS Trust): The trust has compiled a spreadsheet of clients identified as being worked with by Adult Mental Health and Substance Misuse Services, which is updated at the Southampton Alcohol Recovery Service …
Responded
Kymberley Holden
Concerns: Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.
Overdue
Christiana Pelle
Concerns: The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the absence of a system for sharing information between the Community District Nursing Team and other agencies, and a lack of a system for communicating concerns with the care provider agency.
Overdue
Jonathan Zucker
Concerns: A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Response (PSYCH): The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to …
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal …
Responded
Lee Swain
Concerns: A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.
Overdue
Margaret Conway
Concerns: Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.
Overdue
Beryl Varcoe
Concerns: Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of existing users.
Overdue
Sharon Halliwell
Concerns: The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.
Response (North West Boroughs Healthcare NHS Trust): A "theme of the week" communication has been shared across the organisation regarding connectivity of electronic care systems. IAPT staff have received RiO training.
Responded
Andrew Reid
Concerns: Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.
Responded
Barbara Ellis
Concerns: A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.
Overdue
Sufia Begum
Concerns: Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking preventable deaths from unknown medication interactions.
Responded
Paul Allan
Concerns: The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap in mental health support.
Response (Pennine Care NHS Trust): The Trust will circulate a reminder to all staff regarding the CPA policy and how to access it. Pennine Care NHS is a signatory to the Greater Manchester Strategic suicide …
Responded
David Stacey
Concerns: A statutory requirement to provide beds for mentally disordered patients in special urgency cases is being ignored, leading to a lack of identifiable beds for high-need individuals.
Overdue
Robin McEwan
Concerns: Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Response (Harrogate CCG): The CCG will review the primary care referral process for private counselling, look at developing Mental Health & Psychological First Aid within Primary Care and the CCGs, and further develop …
Responded
Brian Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Overdue
Charles Grainger
Concerns: Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.
Overdue
Canon Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Response: The Diocese will conduct annual property and safety assessments for retired priests, involving a surveyor, welfare officer, and the priest. Necessary repairs will be organised and paid for by the …
Overdue
Committee Recommendations (321) — showing 50 strongest matches
#12 —
Recommendation: Locally-commissioned employment support will require close working between local government and a variety of partners, including the NHS. Integrated care systems (ICSs) have an important role to play in strengthening these partnerships. The Government’s ambition is for every area in …
Gov response: Jobcentre staff undergo comprehensive ongoing learning which continues at point of need throughout their role. This provides them with the knowledge and skills training to enable them to treat each claimant as an individual and …
Under Consideration
#48 —
Recommendation: Planning for future pandemics should have a more developed and explicit consideration of the intense interaction between the NHS and social care. The prominence of social care within the Department of Health and Social Care should be enhanced and Ministers …
Gov response: The government accepts this recommendation. Recommendation 293 is about the need for planning for future pandemics to have a more developed and explicit consideration of the intense interaction between the NHS and social care; enhancing …
Under Consideration
#48 —
Recommendation: Planning for future pandemics should have a more developed and explicit consideration of the intense interaction between the NHS and social care. The prominence of social care within the Department of Health and Social Care should be enhanced and Ministers …
Gov response: The government accepts this recommendation.
Under Consideration
#27 —
Recommendation: In light of the Government’s commitment to reform social care, we again recommend that it publishes a ten-year plan for social care, setting out how it in detail how it will tackle the structural and financial problems the sector faces …
Gov response: The Government recognises the importance of social care in supporting hospital discharge and freeing up capacity. The Government has made available up to £7.5 billion over the next two years to support adult social care …
Under Consideration
#34 —
Recommendation: Integration strategies should seek to integrate not just health and care but health, care and housing. Ensuring there is holistic care that fits around a person’s needs includes preventing care needs from arising by having suitable housing, enabling people to …
Gov response: The government agrees that ensuring there is holistic care that fits around people’s needs includes ensuring that people receive the right care and support, and can maintain healthy independent living, beginning with where they live, …
Not Addressed
#33 —
Recommendation: We welcome the Joining up Care for People, Places and Populations White Paper and commend the Government for making the integration of health and social care a policy priority. We particularly welcome the Government’s ambitions around shared outcomes, workforce integration, …
Gov response: Whilst strategic, at-scale planning and commissioning is at integrated care system (ICS) level, the government recognises much of the activity to integrate care should be driven by collaboration between commissioners and providers over smaller geographic …
Accepted
#4 —
Recommendation: These reforms do nothing to address the longstanding tension caused by differences in funding and accountability arrangements between the NHS and social care. The Department, which has policy responsibility for both health and social care, is showing a worrying lack …
Gov response: The government disagrees with the Committee’s recommendation. The structures and processes in the Health and Social Care Act 2022 are specifically designed to ensure that different partners of the system support each other to overcome …
Not Accepted
#41 — Women's health hub model shows promise but faces systemic challenges and risks unequal access.
Recommendation: The expansion of the women’s health hub model has the potential to be a positive step towards providing the joined-up care and commissioning needed to effectively support women experiencing reproductive health conditions. However, the women’s health hub model exists within …
Gov response: We are committed to moving towards a neighbourhood health service, with more care delivered in local communities, to identify and address problems earlier and closer to home. Women’s health hubs are an example of this …
Not Addressed
#2 — Ensure DfE and DHSC collaborate to understand rising SEN demand and propose efficient support provision.
Recommendation: Without fully understanding why demand for support has increased, the Department’s ability to provide value for money is undermined. Over the last decade, demand for EHC plans has soared. In January 2024, there were 3 576,000 children with EHC plans, …
Gov response: The government agrees with the Committee’s recommendation. committed to delivering a more inclusive education system based on early intervention. While it cannot commit to setting out plans in the next six months, it will set …
Accepted
#24 — Overall NHS productivity remains low despite increased elective activity and community investments.
Recommendation: Despite carrying out 15% more elective activity than before the pandemic, the NHS is less productive overall once the activities of mental health trusts, community trusts and GPs are considered.42 NHSE told us that, while government has had a long-term …
Gov response: 6.2 NHS investment in primary medical care and community services (including continuing care) increased faster than overall ICB spend in 2023-24. 6.3 DHSC and NHSE have prioritised mental health in its plans for 2025-26, requiring …
Not Addressed
#13 — DHSC acknowledges long-term healthcare shifts but prioritises immediate acute service pressures.
Recommendation: DHSC and NHSE told us that they were fully supportive of the new government’s aims to shift healthcare spending from treatment towards prevention, from hospitals to the community, and from analogue to digital. However, DHSC contended that these shifts would …
Gov response: 2.2 The underlying financial position of the NHS providers and systems is significantly improved in 2024-25 compared to 2023-24 with an end of year deficit of around £600 million compared to £1.5 billion in the …
Not Addressed
#9 — Discrepant budget timings impede joint strategic planning between local authorities and NHS bodies.
Recommendation: We asked how local authorities and NHS bodies could be expected to work together and deliver a joint strategy when local authorities receive provisional budgets in December, and final ones by February, but NHS 8 C&AG’s Report, paras 1.6 and …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: December 2025 1.2 NHS England publishes planning guidance as soon as funding is finalised and approval is received by Government, in recent years this has …
Accepted
#6 — Ensure greater NHSE funding for community services, preventing redirection to hospitals.
Recommendation: NHSE’s long-held ambition to move more care from hospitals to the community has stalled. There would have been more investment and progress in mental health and community services, particularly GP surgeries and dental services, in 2023–24 had NHSE not redirected …
Gov response: The government is considering this recommendation. care) increased faster than overall ICB spend in 2023-24. DHSC and NHSE have prioritised mental health in its plans for 2025-26, requiring ICBs to meet the Mental Health Investment …
Under Consideration
#28 — Ensure alignment of Integrated Care Systems reforms with local government and adult social care
Recommendation: The Department for Health and Social Care must ensure that the ongoing reforms and cuts to Integrated Care Systems and Integrated Care Boards are aligned both with wider reorganisation of local government and with necessary reforms to the adult social …
Gov response: 79. The Government published a strategy in December 2024 which set out the purpose of local audit including a vision statement and key principles. The Local Audit Office (LAO) will be set up next year …
Under Consideration
#31 — Local tailoring of employment services is welcome, but requires balance with national consistency.
Recommendation: We welcome the Government’s commitment to develop a locally tailored and embedded service. Local areas are best placed to understand the needs of their population and labour markets. Jobcentres need to be aware of the different local needs of people …
Gov response: We welcome the Government’s commitment to develop a locally tailored and embedded service. Local areas are best placed to understand the needs of their population and labour markets. Jobcentres need to be aware of the …
Not Addressed
#28 — Detail plans for revitalising the Jobcentre estate, ensuring adaptability and co-location of services.
Recommendation: In its response to this report, DWP should set out how it will use its increased capital funds to revitalise the Jobcentre estate. DWP needs to make more of its Jobcentre spaces and it should make sure that the physical …
Gov response: Accept Through capital investment, DWP is committed to transforming our Jobcentre spaces so that our physical infrastructure is adaptable and responsive to the needs of our customers, colleagues, and local and national partners. The Workplace …
Accepted
#25 — Audit existing Jobcentre partnerships with the voluntary and community sector to develop new operational models.
Recommendation: DWP should improve how it works with the voluntary and community sector, but first it needs to understand its current position. DWP should undertake an audit of its existing partnership work. It should use this to develop new operational models …
Gov response: Partially accept DWP recognises the invaluable part played by the voluntary and community sector in supporting customers alongside DWP and agrees that forming a more coherent view of the current position is useful. As part …
Partially Accepted
#24 — Jobcentres require deeper integration with voluntary and community sectors to address complex employment barriers.
Recommendation: Many people who use Jobcentres have multiple and complex needs, which can act as barriers to them securing employment. Too often, issues that prevent people from finding jobs go unaddressed. Jobcentres and Jobcentre staff will not be able to address …
Gov response: Partially accept DWP recognises the invaluable part played by the voluntary and community sector in supporting customers alongside DWP and agrees that forming a more coherent view of the current position is useful. As part …
Partially Accepted
#2 — Inconsistent FGM survivor services and poor referral pathways create postcode lottery
Recommendation: Services for FGM survivors and access to them remains inconsistent across the UK. While some variation in access to services may be expected in line with local prevalence, there is a lack of effective referral pathways. This has created a …
Gov response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending on …
Accepted
#25 — Lack of a joined-up data plan hinders understanding of outcomes for children.
Recommendation: We asked MoJ and DfE why the system was not working as well as it should, given that better data sharing should allow improvements, and whether this was evidence of complacency.58 Delays in cases weigh heavily on children, in particular, …
Gov response: We asked MoJ and DfE why the system was not working as well as it should, given that better data sharing should allow improvements, and whether this was evidence of complacency. Delays in cases weigh …
No Published Response
#23 — No overall assessment exists for prioritising efforts to reduce family justice delays.
Recommendation: An overall assessment of the drivers of performance is important to support the system to focus on areas most likely to secure improvements. A whole-system approach is needed to deliver outcomes no individual body can achieve alone.50 MoJ told us …
No Published Response
#21 — Case complexity, administrative landscape, and staff shortages contribute to London court delays.
Recommendation: MoJ and HMCTS told us that cases can take longer in London partly because there are more complicated cases, often with international dimensions. There is also a complicated administrative landscape with 33 different local authorities all doing things differently.44 HMCTS …
No Published Response
#13 — Absence of shared strategy for family justice system across departments.
Recommendation: There is no shared strategy for the whole system across all the departments involved. DfE told us that there is a published strategy document for children’s social care, and that the FJB has shared objectives and targets. MoJ and DfE …
No Published Response
#11 — Family justice system lacks single accountability due to dispersed responsibilities.
Recommendation: Successful delivery of services requires strong accountability with clear roles and responsibilities. Responsibilities for family justice are dispersed across many organisations across government and there is no single body accountable for overall performance. Complex and fragmented funding arrangements and information …
No Published Response
#2 — Assess and report on improving accountability for family justice system by December 2025.
Recommendation: The family justice system is complex, but excessive fragmentation hinders transparency, leading to poor accountability for service improvement and overall performance. The family justice system involves many organisations across government and the independent judiciary. There is no single body accountable …
Gov response: The government agrees with the Committee’s recommendation. weaknesses of current governance arrangements with a view to improving accountability and transparency, along with better supporting the National and Local Family Justice Boards. Departments will write to …
Accepted
#85 — Place a clear statutory duty on health services for full participation in SEND provision.
Recommendation: The Government should place a clear statutory duty on health services, including ICBs and NHS providers, to ensure their full and accountable participation in the planning, commissioning, and delivery of SEND provision. This duty must align with the Children and …
Gov response: Ongoing health and social care engagement is essential in delivering effective education and support to children and young people with EHCPs. The SEND Tribunal currently makes non-binding decisions in relation to health and social care …
Not Addressed
#84 — Appoint a dedicated national SEND lead within DHSC to drive health system accountability.
Recommendation: The Department of Health and Social Care must urgently appoint a dedicated national SEND lead to drive accountability and coordination across the health system. This role must be empowered and mandated to provide coherent strategic leadership on the delivery of …
Gov response: The Department is working closely with DHSC and NHS England to improve access to community health services, such as speech and language therapy, for children and young people with SEND. As set out in the …
Accepted
#83 — Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
Recommendation: The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with …
Gov response: The Government is grateful to the Education Select Committee for its inquiry report into Solving the SEND Crisis and we welcome the opportunity to respond to the Committee. Every child should have a childhood rich …
Not Addressed
#81 — Require health sector financial investment and robust partnership arrangements by autumn 2026.
Recommendation: Crucially, this must be backed by appropriate financial investment from the health sector to meet statutory duties, provide timely access to therapies and assessments, and contribute equitably to joint commissioning arrangements. All areas should have a robust and fully operational …
Gov response: The Department is working closely with DHSC and NHS England to improve access to community health services, such as speech and language therapy, for children and young people with SEND. As set out in the …
Not Addressed
#80 — Utilise NICE expertise to produce new evidence-led SEND guidelines and intervention pathways.
Recommendation: Bringing education and health more closely together should be supported by an evidence led approach, drawing on the role of NICE (National Institute for Health and Care Excellence) to produce new SEND guidelines and intervention pathways. (Recommendation, Paragraph 277)
Gov response: Effective. Reforms should be grounded in evidence, ensuring all education settings know where to go to find effective practice that has excellent long-term outcomes for children. As set out in the 10 Year Health Plan, …
Partially Accepted
#79 — Identify SEND as health system priority, strengthening ICB accountability and senior officer visibility.
Recommendation: SEND should be identified as a priority across the health system and ongoing NHS restructuring must be used as an opportunity to strengthen the role and accountability of health services in supporting children and young people with SEND. This includes …
Gov response: Shared. Education, health and care services should work in partnership with one another, local government, families, teachers, experts and representative bodies to deliver better experiences and outcomes for all our children. The Department is working …
Not Addressed
#78 — SEND not a shared priority across government departments, burdening the education system.
Recommendation: The current failure to embed Special Educational Needs and Disabilities (SEND) as a shared priority across government departments is not just a policy oversight, it is a profound injustice to some of the most vulnerable children in our society. It …
Gov response: Shared. Education, health and care services should work in partnership with one another, local government, families, teachers, experts and representative bodies to deliver better experiences and outcomes for all our children. The Department is working …
Not Addressed
#67 — Develop joint SEND workforce plan to address shortages and re-deploy professionals therapeutically
Recommendation: The DfE and DHSC should urgently develop a joint SEND workforce plan to address shortages and build capacity across education, health, and care services. This should include explicit measures to deliver a shift in the deployment of educational psychologists, speech …
Gov response: The Department is working closely with DHSC and NHS England to improve access to community health services, such as speech and language therapy, for children and young people with SEND. As set out in the …
Partially Accepted
#33 — Improve cross-departmental coordination and strengthen accountability for SEND health services at ICB level.
Recommendation: The Department for Education must significantly improve cross- departmental coordination with the Department of Health and Social Care and NHS England to establish clear, consistent accountability for SEND at the ICB level. Current arrangements are fragmented and lack clarity. Strengthening …
Gov response: The Department is working closely with DHSC and NHS England to improve access to community health services, such as speech and language therapy, for children and young people with SEND. As set out in the …
Not Addressed
#30 — Strengthen accountability frameworks for health partners to ensure full integration into the SEND system.
Recommendation: The limited engagement of health services in the SEND system stems from a lack of robust and enforceable accountability mechanisms. Despite being a critical enabler of positive educational outcomes for children with SEND, health services are not held to the …
Gov response: Ongoing health and social care engagement is essential in delivering effective education and support to children and young people with EHCPs. The SEND Tribunal currently makes non-binding decisions in relation to health and social care …
Not Addressed
#15 — Strengthen local authorities' ability to deliver EHC plans by compelling other services
Recommendation: Where EHC plans are issued, they carry a statutory duty which must be delivered in full. To make this a reality, the Department for Education should strengthen the ability of local authorities to meet these obligations by ensuring that the …
Gov response: Similarly, we recognise that the importance of ensuring that schools and local authorities are accountable for the services they have a duty to provide for children and young people with SEND. The Local Government and …
Not Addressed
#7 — Outline collaboration among public financial institutions and re-examine merging British Business Bank and NWF.
Recommendation: The new NWF strategy must explicitly state how those public financial institutions will work together to ensure that businesses that are scaling up can seamlessly obtain support without gaps or duplication. The Treasury should re-examine the potential merits of merging …
Gov response: The government strongly agrees that public financial institutions must work together to ensure businesses can access support seamlessly with no gaps or duplication. To drive this, the government established the Public Investment Roundtable (PIR) (formerly …
Partially Accepted
#24 — Facilitate a greater role for local authorities to accelerate domestic retrofit roll-out.
Recommendation: We look forward to the Government’s Warm Homes Plan and their estimate of workforce needs and how they will meet it. The Government’s Warm Homes Plan should facilitate a greater role for local authorities to accelerate the roll-out of retrofit. …
Gov response: The government agrees with this recommendation Over time, the Warm Homes Plan is projected to increase the number of jobs supported in energy efficiency and clean heating from 60,000 in 2023, to up to 240,000 …
No Published Response
#14 — Empower devolved governments and resource coordination for consistent training and skill portability.
Recommendation: We welcome the Government’s attention to leveraging the significant potential of various levels of devolved government across different parts of the UK. They should be empowered to lead on approaches tailored to local or regional strengths and weaknesses. Furthermore, the …
Gov response: The government agrees with this recommendation. As stated in the Clean Energy Jobs Plan, devolved governments, Mayoral Strategic Authorities (MSAs), and local authorities are pivotal in shaping and delivering a responsive, place-based skills system. The …
No Published Response
#12 — Devolved governments are crucial for national workforce planning, ensuring consistent quality and skill portability.
Recommendation: National workforce planning will need to be delivered beyond Whitehall and devolved levels of government have a crucial role to play. National plans need to recognise that delivery of the workforce may diverge according to local circumstance and need while …
Gov response: The government agrees with this recommendation. As stated in the Clean Energy Jobs Plan, devolved governments, Mayoral Strategic Authorities (MSAs), and local authorities are pivotal in shaping and delivering a responsive, place-based skills system. The …
No Published Response
#23 — Consider interconnected challenges in fragile states when deploying ODA financial and human resources holistically.
Recommendation: We urge the Government to consider the nature of interconnected challenges such as nutrition, food systems, education, Water Sanitation and Hygiene, and governance challenges—particularly in relation to fragile and conflict-affected states—as it plans how it will deploy its financial and …
Gov response: 34. The FCDO is transitioning to differentiated development partnerships based on mutual benefit – taking account of country need and long term UK interest. The UK will prioritize our geographic ODA where humanitarian needs are …
No Published Response
#10 — Encourage collaboration among missions to efficiently utilise funds and expertise on shared opportunities.
Recommendation: Where missions across a region, or a thematic area, have identified shared opportunities and solutions, collaboration should be encouraged. Supporting such initiatives will be an efficient use of limited funds as well as a good utilisation of expertise, whether in …
Gov response: Partially agree 22. The FCDO is taking a partnership-led approach to development. As part of this, our country network will have the flexibility to deliver the development our partners want and the FCDO is also …
No Published Response
#28 — Provide details of ministerial working group meetings and expand to include frontline agencies
Recommendation: In its response to this report, the Government should provide details on how many times the group has met since September 2025 and share minutes of its discussions. Defra should expand the ministerial working group to include an additional operational …
Gov response: The government partially accepts this recommendation. As set out above, the newly established Illegal Imports Improvement Project brings together a range of workstreams and stakeholders to focus on delivery of meaningful improvements to the current …
No Published Response
#26 — NHSE abolition announced alongside significant cost-cutting demands on Integrated Care Boards
Recommendation: On 13 March 2025, the Government announced that NHSE would be abolished within two years and that the Department would put in place arrangements to deliver the responsibilities currently delivered by NHSE.57 On the same day, as part of our …
Gov response: 6.6 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2026 6.7 The department accepts the Committee’s recommendation and will deliver a modernised health system through the integration of NHS England into DHSC …
Accepted
#25 — NHSE working to improve clinical engagement for outpatients, but the fundamental care model requires change.
Recommendation: NHSE accepted that any reform or change management programme cannot work without clinical engagement, and told us that it was now carrying out a range of activities to secure clinical support for the outpatients programme. NHSE explained that, among other …
Gov response: 5. PAC conclusion: NHS England’s performance to date has not demonstrated that it can secure the clinical engagement that will be necessary to transform waiting lists. 5. PAC recommendation: The Department should set out what …
Accepted
#5 — Require the Department to set out new plans for securing clinical engagement on outpatient transformation.
Recommendation: NHS England’s performance to date has not demonstrated that it can secure the clinical engagement that will be necessary to transform waiting lists. Clinical engagement has worked best when there been close working between national and local clinical leaders, and …
Gov response: The government agrees with the Committee’s recommendation. for successful outpatient transformation and has been the main challenge in previous transformation efforts. DHSC and NHS England are strengthening clinical engagement and ensuring clinicians are delivery partners …
Accepted
#4 — Require NHSE and Department to set out plans for elective care digital transformation and IT connectivity.
Recommendation: We are not confident that the Department is being realistic about the immense effort needed to reduce NHS elective care waiting times, and see a significant risk that digital solutions are being treated as a ‘cure- all’ as the 10 …
Gov response: The government agrees with the Committee’s recommendation Recommendation implemented The government is providing record investment in the health and social care system. The 10 Year Health Plan is affordable within the Department of Health and …
Accepted
#29 — Full regional commissioning model remains untested, raising concerns over scope and accountability.
Recommendation: The Department has not confirmed how it will test the full commissioning model, and stakeholders have highlighted the scale of change and the need for a strong evidence base.80 The Children’s Homes Association told us that it was unclear how …
Gov response: 6. PAC conclusion: The Department has failed to address the problem of local authorities competing for places and the effect that has on driving up costs. 6. PAC recommendation: The Department should clarify, as part …
Response Pending
#28 — Regional commissioning pilots delayed and limited, with national rollout potentially taking ten years.
Recommendation: The MacAlister review envisaged regional organisations operating fully from early 2025, to address sufficiency challenges by 2027. The Department decided against immediately rolling out regional commissioning nationally given insufficient evidence on potential benefits, instead opting for pilots in two regions, …
Gov response: 6. PAC conclusion: The Department has failed to address the problem of local authorities competing for places and the effect that has on driving up costs. 6. PAC recommendation: The Department should clarify, as part …
Accepted
#27 — Department accepts recommendations for regional commissioning to improve children's residential care provision.
Recommendation: The Department accepted recommendations to introduce regional commissioning made by the Competition and Markets Authority and Josh MacAlister in 2022. The MacAlister review recommended that local authorities should group together in regional organisations, taking collective responsibility for running public-sector residential …
Gov response: 6. PAC conclusion: The Department has failed to address the problem of local authorities competing for places and the effect that has on driving up costs. 6. PAC recommendation: The Department should clarify, as part …
Response Pending
CQC Inspection Actions (3)
Tralee Rest Home
The provider could develop closer working between sister services and this may serve to improve consistency and best practice.
Should Do
Gillmoss Medical Centre
Implementadetailedstrategytosupporthighqualityandsustainablecare.
Should Do
Shining Star Home Care Limited
Improvements were required to ensure the provider worked in partnership with external agencies and relatives to ensure people received a holistic service.
Should Do
HMICFRS Recommendations (2)
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables should explore opportunities to improve how their force works with partners to contribute to a multi-agency response to stalking, including healthcare, CPS, probation collaboration, inter-force collaboration, and MAPPA utilisation for stalking offender management.
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables and police and crime commissioners should work together to review commissioning arrangements and embed collaborative working and information sharing between policing and victim support services.
Recommendation
PPO Death in Custody Recommendations (9)
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC …
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC and NHS England, should explore options for developing a pathway for prisoners who have been assessed as needing residential social care to access an appropriate care setting. This work should …
The Head of Healthcare
The Head of Healthcare should ensure that there is a local process to maintain oversight of regional bed referrals and any required escalation.
The Head of Healthcare
there are clear processes and pathways in place to enable staff to make timely onward referrals;
The Head of Healthcare
improve communication between healthcare and mental health services and ensure that feedback and advice on how to manage complex cases is provided to those who make referrals;
The Governor and Head of Healthcare
The Governor of Wakefield and Head of Healthcare should develop and implement a multidisciplinary information-sharing protocol, for the purposes of care planning and risk assessments, that ensures information is shared appropriately between disciplines inputting into an individual’s care.
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should review and improve communication methods for liaising with hospital consultants and clinics, and evidence changes in system management to NHS England commissioners.
The Head of Healthcare
The Head of Healthcare should engage with a senior clinical hospital colleague in order to improve the discharge information process between the hospital provider and HMP Stafford.
The Director General of HMPPS, NHS England, and the Association …
The Director General of HMPPS should work with NHS England and the Association of Directors of Adult Social Services with the aim of developing a strategy to meet the needs of prisoners not suitable for release but who need an …
The Governor and Head of Leeds Probation Delivery Unit
Information sharing between all relevant agencies is key to release planning and the Governor and Head of Leeds Probation Delivery Unit may want to reflect on the learning from this case.
IOPC Learning Recommendations (4)
Recommendations - Cambridgeshire Constabulary, January 2021
The IOPC recommends that Cambridgeshire Constabulary considers working with local health boards to amend their inter-agency agreement to enable a mental health assessment made by Norfolk health care professionals to be accepted by Cambridgeshire health boards and vice versa. The …
Recommendations - Metropolitan Police Service, March 2021
The IOPC recognise the protracted nature of drafting and agreeing MOUs, therefore the IOPC recommend that in any event the Metropolitan Police Service (MPS) should create and deliver joint mental health awareness training with London-based Mental Health trusts, including the …
Recommendations - Metropolitan Police Service, March 2021
The IOPC recommends that the Metropolitan Police Service (MPS) create a Memorandum of Understanding (MOU) between all London-based Mental Health Trusts and the PAN London Mental Health Group. It is recommended that this MOU includes the following points: joint mental …
Recommendations - Gwent Police, February 2021
The IOPC recommends that Gwent Police engages with external agencies, who regularly request the police to conduct welfare checks on their behalf, and establishes a Memorandum of Understanding. This is to ensure that both the agencies and Gwent Police are …
NAO Audit Recommendations (27)
Reforming adult social care in England
As it turns its attention to charging reform alongside system reform, DHSC should publish a long-term plan mapping its reform activity and the funding it will need to achieve its planned outcomes
Rejected
Reforming adult social care in England
As it turns its attention to charging reform alongside system reform, DHSC should ensure it has the resources it will require within the Department, in terms of both capacity and capability to deliver the next stage of reform
Accepted
Reforming adult social care in England
DHSC should, in the near term, assess the impact of its current and planned reform interventions on local authorities, and other stakeholders to ensure that the cumulative impact of its policies are manageable;
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
a) DHSC and the Department for Levelling Up, Housing & Communities should, by April 2023, establish transparent arrangements across government and with wider stakeholders to tackle the drivers of poor health outcomes, including education, employment, benefits, and transport;
Accepted
The adult social care market in England
The Department should: a) as a priority, set out a cross-government, long-term, funded vision for care. It should collaborate with the Ministry and local government in particular; factoring in sector and user perspectives, such as people with lived experience;
Accepted
The supply of personal protective equipment (PPE) during the COVID-19 pandemic
Despite efforts to integrate them over the years, health and social care have continued to be separate systems. During this crisis the social care sector was hit hard by shortages of PPE, and government needs to understand why national bodies …
Partially accepted
Local government financial sustainability
As part of the spending review, and to support a cross-departmental approach, we recommend that HM Treasury: work to provide a spending framework that supports the government?s plans for local government funding and service reform
Accepted
Local government financial sustainability
We recommend that MHCLG: work with the local government sector to improve the transparency and consistency of local authority reporting on reserves to aid understanding of local authorities? overall financial positions;
Accepted
Local government financial sustainability
We recommend that MHCLG: explore how the impact of preventative services can be evaluated and incentivised to deliver better outcomes and improved value for money
Accepted
Local government financial sustainability
We recommend that MHCLG build on recent announcements to develop a whole-system approach to local government financial sustainability. This approach would consider interdependencies and consequences across services and departmental boundaries and should be underpinned by clear expectations of local government. …
Accepted
Local government financial sustainability
We recommend that MHCLG build on recent announcements to develop a whole-system approach to local government financial sustainability. This approach would consider interdependencies and consequences across services and departmental boundaries and should be underpinned by clear expectations of local government. …
Accepted
Support for children and young people with special educational needs
DfE and the wider government should: c) build a more integrated system by, for example, developing a shared understanding of how identifying and supporting SEN should be prioritised, including within the health system; ensure those with accountability can act, including …
Accepted
Reforming adult social care in England
As it turns its attention to charging reform alongside system reform, DHSC should review its arrangements for delivering and overseeing its reform activity, incorporating external challenge, and to conclude whether a more integrated approach is required going forward.
Accepted
Reforming adult social care in England
DHSC should, in the near term, set out a costed plan to the sector for implementing charging reform from October 2025, incorporating lessons learnt so far
Rejected
Reforming adult social care in England
DHSC should, in the near term, review its portfolio reporting to ensure that it provides the management information needed to give assurance around overall progress and management of risks to delivery
Accepted
Improving educational outcomes for disadvantaged children
DfE should take a clearer whole-system approach by more clearly setting out how the range of its interventions come together, to help: understand how they individually and collectively support the attainment of disadvantaged children; ensure that objectives are aligned; and …
Accepted
Reducing the backlog in criminal courts
b) develop a shared understanding of the capacity and capability of other parts of the criminal justice system, including the CPS and the legal professions, to support recovery in criminal courts.
Accepted
Reducing the backlog in criminal courts
• set reasonable expectations around waiting times by case type, acknowledging the responsibility of the judiciary.
Accepted
Reducing the backlog in criminal courts
• align recovery funding, planning and reporting across criminal justice agencies; and
Accepted
Reducing the backlog in criminal courts
The Ministry should: a) agree with other criminal justice agencies a set of shared, published objectives for recovery in criminal courts that explicitly consider the implications for the rest of the criminal justice system. It should use these shared objectives …
Accepted
Test and trace in England – progress update
e) The Department, through NHST&T, and UKHSA if responsible, should agree with NHS England and NHS Improvement whether and how the laboratory capacity built up for COVID-19 tests will be used by the NHS. It should publish by March 2022 …
Partially accepted
The adult social care market in England
f) consult on options for enhancing support for local commissioners which promotes an integrated approach and incentivises commissioning for outcomes; and
Accepted
Local government finance in the pandemic
To further improve other elements: b) other departments, drawing on the support of the Department, should improve their links with, and understanding of, local authorities, drawing on learning from the Social Care Sector COVID-19 Support Taskforce;
Accepted
The effectiveness of government in tackling homelessness
We recommend that DLUHC should lead on adopting a genuinely cross-departmental approach to tackling homelessness, which might involve establishing a dedicated joint unit to oversee the implementation of the approach
Accepted
Improving educational outcomes for disadvantaged children
DfE should take a clearer whole-system approach by setting out how it will more effectively engage with wider government to help develop a shared vision, robust joint risk assessment, clear responsibilities, and an understanding of how respective departmental priorities could …
Accepted
NHS Financial Management and Sustainability
NHSE and DHSC should revisit their understanding of the reasons some ICBs and other NHS bodies have persistent underlying weaknesses that lead them to struggle with their finances. They should then develop a plan to remove these barriers.
Accepted
NHS Financial Management and Sustainability
NHSE needs to complete its annual planning processes with ICSs well in advance of each financial year starting. All key players, including NHSE, DHSC and HM Treasury, have roles to play to enable planning guidance to be provided in a …
Accepted
IMB Recommendations (122) — showing 50 strongest matches
Bedford (2022)
We believe that there would be significant benefits in the co-location of healthcare and mental health services and are disappointed that this has not yet happened.
Governor / Director
Bronzefield (2024)
How does NHS England plan to improve the integration of the healthcare services in Bronzefield? (6.1)
NHS / Healthcare Provider
Bronzefield (2024)
How does the Minister plan to improve the integration of the healthcare services (under NHS England commissioning) within Bronzefield? (6.1)
Ministry of Justice
Derwentside IRC (2023)
To establish or improve pathways with local authorities and other external agencies, including probation, to enable prompt access to housing, social support and other services, which are required to be put in place before vulnerable women leave detention
Home Office
Thameside (2024)
The lack of adequate probation support, both for prisoners about to be released and in the community once they are released, is one highlighted by this Board and other Boards for a number of years. It is widely accepted that such support reduces recidivism. Will the new Minister consider: o an increase in the probation support available for prisoners; and …
Ministry of Justice
Durham (2024)
How will you ensure the alignment of operational and healthcare regimes?
Governor / Director
Nottingham (2025)
How does the Prison Service plan to ensure a more cohesive working relationship between the healthcare provider and the prison?
HMPPS
Cardiff IMB (2025)
Sut bydd y carchar yn gweithio gyda chyngor Caerdydd i sefydlu proses gofal cymdeithasol ffurfiol a chadarn, o ystyried nad oes un yn bodoli, fel yr amlygwyd yn yr Asesiad o Anghenion Iechyd a Gofal Cymdeithasol?
Governor / Director
Cardiff (2025)
How will the prison work with Cardiff council to establish a formal and robust social care process, given that none exists, as highlighted in the H&SCNA?
Governor / Director
Bronzefield (2025)
What further steps will the Minister take to address the integration of the healthcare services (under NHS England commissioning) within Bronzefield, notwithstanding the Memorandum of Understanding referred to in the Minister’s letter of response to the Board’s 2023-2024 annual report (on 17 January 2025) (6.1)?
Ministry of Justice
The Verne (2020)
The Board encourages the Governor, in collaboration with Dorset Council, to review the long-term provision of social care needs for the current population.
Governor / Director
Long Lartin (2020)
The Board believes that there is a need for closer cooperation between HMPPS management and the healthcare providers, in order to help them to achieve a better service.
Governor / Director
Bedford (2020)
Explore the possibilities of co-locating the healthcare team and the mental healthcare team.
Governor / Director
The Verne (2021)
The Board urges HMPPS to expedite the establishment of the ‘community hospital’ and a facility enabling 24hr social care at The Verne.
HMPPS
The Verne (2022)
The Board urges HMPPS to expedite the establishment of a facility enabling 24-hour social care at The Verne (para. 6.3.5).
HMPPS
Downview (2022)
It has been regrettable that there has been such a lack of stability with the management of healthcare during the reporting year and this has undoubtedly impacted on provision. We are reassured to see a permanent healthcare head appointed shortly after the end of the reporting period, which hopefully will lead to a more concerted effort on behalf of the …
Governor / Director
Woodhill (2023)
To work with colleagues in the Department of Health and Social Care to consider how the pathway through secondary care could be streamlined for prisoners who are transferred after their referral.
Ministry of Justice
Thameside (2023)
The Board has been concerned regarding the management of the changeover of healthcare provider; while recognising some disruption was inevitable, the level of disruption has been greater than expected and unacceptable, impacting negatively on prisoners’ ability to access adequate healthcare.
HMPPS
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Hewell (2023)
What is the Prison Service doing to improve the effectiveness of agencies working together to achieve effective release and resettlement? Despite good work being done by individual agencies, we see men being released without the dots having been joined; this negates in-prison work done to achieve positive resettlement and may increase the chances of homelessness, unemployment and re-offending.
HMPPS
Downview (2023)
Does the prison consider there to be a benefit in the healthcare/prison partnership meetings and, if so, will appropriate resources be dedicated to them?
Governor / Director
Askham Grange (2023)
Can the Prison Service consider improving the provision of community offender managers to help speed up access to ROTLs and improve release planning?
HMPPS
Springhill (2024)
The Board continues to report issues with securing the necessary information and engagement from outside probation and other agencies, which significantly delay men’s access to release on temporary licence (ROTL). An issue which is exacerbated by the introduction of new early release schemes. What more does the Prison Service intend to do to improve the capacity of outside probation and …
HMPPS
Haverigg (2024)
When will the Minister improve the range of support services for an increasing number of very frail elderly prisoners (80+ years) who have complex physical, mental health and social care needs? Does the Minister consider that prison is a suitable environment for this cohort of prisoners? If not, what are the alternatives?
Ministry of Justice
Dartmoor (2024)
What progress has been made on the provision of overnight care at a category C prison in Devon? When will it be introduced?
HMPPS
Peterborough (2025)
For the men’s prison, what specific steps are being taken to ensure that the care of prisoners benefits fully from a multidisciplinary approach that makes better use of the resources now available?
Governor / Director
Durham (2025)
How will you ensure the alignment of operational and healthcare regimes? (6.2.13)
Governor / Director
Ashfield (2025)
Pressure on probation services inside and outside prison. Concern about prisoners being released without appropriate accommodation. What further measures are being taken to address this problem?
Other
Bronzefield (2025)
How does NHS England plan to improve the integration of healthcare services in Bronzefield (6.1)?
NHS / Healthcare Provider
Thorn Cross (2020)
An additional concern is the healthcare needs of prisoners who transfer to Thorn Cross while in the process of hospital and other clinical treatment at their current establishment. These prisoners, who require ongoing treatment at specialist centres, cannot easily or quickly be referred to local medical facilities. To enable these prisoners to continue their treatment, significant additional resource requirements are …
HMPPS
Hewell (2020)
Similarly, the Board remains concerned about the difficulties encountered in transferring prisoners with severe mental health/behavioural issues to an environment where they can be treated effectively. Again, will the minister work with colleagues in other departments to ensure greater availability of more suitable locations for these prisoners?
Ministry of Justice
Styal (2021)
The Board is concerned about the changes to the contracts for Through the Gate (TTG) Services, including the loss of Shelter who are a known and experienced partner. Whilst TTG services will now be managed by the National Probation Service (NPS), there will still be a number of new external partners, replacing the current partners and based around different geographical …
HMPPS
Maidstone (2021)
Develop a more integrated relationship with HOIE to ensure fair and humane treatment for foreign national prisoners and their families through improved communication and end of sentence management.
HMPPS
Lewes (2021)
Will the Minister engage with the Ministry of Housing, Communities and Local Government to improve the coordination between the prison service and local authorities so that pre-release assessments are completed by both parties in advance of prisoner release in all cases?
Other
Gartree (2021)
The Board acknowledges the Minister’s response to the question raised in our last annual report regarding the national partnership agreement for prison healthcare. The Board requests the Minister provide a further update on resources being planned post-Covid-19 to enable the delivery of measures outlined in the partnership agreement specifically for Gartree, as the Board has increasing concerns regarding the mental …
Ministry of Justice
Cookham Wood (2021)
When will the refurbished Phoenix unit be opened as a functioning integrated care unit?
Governor / Director
Wayland (2022)
The Board recommends to the Governor that the cooperation/collaboration between the operational and the education contractor sides could be significantly improved in order to make better use of an expensive prisoner rehabilitation resource.
Governor / Director
Styal (2022)
consideration needs to be given to a more holistic, multi-agency approach to release arrangements to ensure fair and consistent access to support.
HMPPS
Hull (2022)
The Board would ask the minister to improve the work of outside contractors and organisations responsible for ensuring appropriate accommodation and support is available on release to reduce the risk of re-offending as they are not communicating effectively with the in-prison resettlement team.
Ministry of Justice
Hollesley Bay (2022)
That, as the prison population becomes older, greater attention is paid to the social care agenda and any matters appearing are cross-referenced with the prison’s health service providers.
Governor / Director
Hollesley Bay (2022)
That, as the prison population becomes older, greater attention is paid to the social care agenda and any matters appearing are cross-referenced with the prison’s health service providers.
Governor / Director
Gartree (2022)
Therefore, can the Prison Service confirm to the Board that the integrated health services at Gartree are achieving the outcomes expressed in various commissioning documents, and that the healthcare is equivalent to the local wider community (i.e. the Market Harborough district)?
NHS / Healthcare Provider
Dartmoor (2022)
What is the path for Dartmoor prisoners who require 24-hour health or social care support, or other special equipment or support that Dartmoor is unable to provide?
HMPPS
Thameside (2023)
We ask the Minister to address the shortfalls in probation provision, despite the promised increase in probation staffing, especially in the London area.
Other
Portland (2023)
Need for inter-departmental communication relating to prisoners’ pathways to resettlement
Governor / Director
Hewell (2023)
Address significant shortcomings in the immediate practical resettlement needs of men leaving Hewell, including improvement of inter-agency working, so that no man is found wandering up the drive without the means of reaching a safe destination or ability to meet release conditions.
Governor / Director
Usk and Prescoed (2024)
How will the Minister address the issue of access to support for personal social care for the increasing number of prisoners with limited mobility and other disabilities?
Ministry of Justice
North Sea Camp (2024)
Whilst this was addressed after last year’s annual report, there are still some apparent delays with community offender managers often taking a long time to update their part of the offender assessment system (OASys) risk assessment paperwork to enable prisoners to sit release on temporary transfer (ROTL) boards.
HMPPS
Downview (2024)
How does HMPPS intend to resolve [the lack of commissioned provision for dementia testing in the prison]?
HMPPS
Health Investigations (4)
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 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
Themes and lessons learnt from NHS investigations into matters relating … — Rec R3
The Department of Health and NHS England should facilitate the establishment of a properly resourced forum for voluntary services managers in the NHS through which they can receive peer support and learning opportunities and disseminate best practice.
national
Accepted
Article 2 Learning Points (10)
— LP 8
From a systems point of view, nationally, we further recommend that consideration should be given (a) to the development of a multidisciplinary record, in which Education staff and Chaplains document significant encounters with prisoners, including those not on an ACCT, and (b) to how information systems and care-planning can become …
HMPPS
Accepted
— LP 7
We recommend that, nationally, regarding prisoners on an ACCT, (a) all staff, whatever their profession, having contact with them should record this contact in the ACCT document and (b) that all staff, whatever their profession, involved in their care should attend ACCT reviews.
HMPPS
Accepted
— LP 3
We recommend that across the Prison Service Estate there is more focus on conducting full psychiatric and psychological assessments of prisoners, particularly those with complex needs. This should include the gathering and assimilation of all relevant previous records. This process should be followed by a full psychological formulation with longitudinal, …
HMPPS
Accepted
— LP 6
There should be proportionate information sharing between healthcare and non-healthcare staff so that all staff are aware of the person’s needs, risks, risk factors and likely triggers. Some of this information exchange will be via the ACCT process but there should also be robust handovers at times when staff change …
HMP Altcourse and HMPPS
Accepted
— LP 23
We recommend that efforts are made to ensure that representatives from Healthcare units across the Prison Estate meet on a regular basis. We feel that the key to making this a reality is ensuring that the agenda for such meetings is clear and agreed as a group. Meetings should then …
HMPPS
Accepted
— LP 19
We recommend that officers’ attendance at ward rounds is embedded as a norm on HMP Pentonville’s Healthcare unit, if this is not already the case. This should help further improve understanding and promote a sense of collegiate working among discipline and clinical staff.
PPG
Accepted
— LP 1
At an organisational and cultural level, we recommend that further measures are taken to close the perceived gap between the main prison and the Healthcare unit at HMP Pentonville. This should help create a greater sense that HMP Pentonville is functioning as one organisation, comprised of staff and managers working …
HMPPS
Accepted
— LP K
A multi-disciplinary system for managing Complex Cases should be in place to deal with prisoners such as AC who suffer from a combination of health and behavioural problems.
HMPPS and PPG
— LP G
The partners involved in providing health care to prisoners with mental health problems must be absolutely clear about which service or services have responsibility for prescribing anti-psychotic medication and develop systems to ensure it is prescribed in a timely fashion.
PPG
Implemented
— LP 13
We recommend that the managers responsible for the Southampton court custody suite work with the Hampshire Liaison and Diversion Service to ensure that the service is well understood by custody staff and used effectively.
HMPPS
Accepted
Detention Investigations (11)
Assessment of government progress in implementing the report on the … — Rec 23
The Home Offce and Department of Health and Social Care should prepare a joint communication to IRC healthcare teams clearly laying out health-based entitlements for former detainees released into the community.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 6
Weekly multi-disciplinary review meetings should be held at all IRCs to review and progress cases and ensure appropriate care for the most vulnerable individuals in each centre. These meetings should include a range of managers and staff, and crucially should involve the dialling in of the relevant caseworker for each …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R28
The centre manager and senior Serco managers should continue to engage at all levels with NHS commissioners and G4S to ensure that concerns about the healthcare provision at Yarl’s Wood are addressed.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 58
I recommend that the Home Office, NHS England, and the Department for Health develop a joint action plan to improve the provision of mental health services for those in immigration detention.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 44
I recommend the Home Offce establish an Alternative to Detention project for vulnerable persons who would otherwise be at risk of being detained.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 28
The Home Offce, working with the National Probation Service and Community Rehabilitation Companies, should consider how far vulnerable detainees released from detention can be offered appropriate support and supervision.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 43
I recommend that the Detention Action project for ex-offenders in the community be expanded.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 3
The Home Offce should establish a joint policy with HMPPS on provision for those held in prison under immigration powers.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 17
I recommend that the Home Office consider establishing a joint policy with NOMS on provision for those held in prison under immigration powers.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R44
G4S and the Home Office should discuss relocating the Forward Trust’s office at Brook House so that detainees have ready access to it. (To be completed within 3 months)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 2
The Home Office should consider how far it can encourage a more cohesive system through more joint training and planning, shared communications, and a recognition scheme.
Immigration Detention
PHSO Casework Decisions (97)
P-003682 — Warrington and Halton Hospitals NHS Foundation Trust
Mrs R says the Trust failed to ensure it safely handed over care and management of Mr R’s gallbladder drain to the district nursing team from another local trust in March 2021.
NHS in England
Partly Upheld
Aug 2024
P-003080 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A says the Trust discharged his wife from hospital in June 2023 when she was not fit to do so and without putting a care and support package in place.
NHS in England
Oct 2024
P-003097 — Isle of Wight NHS Trust
Ms H complains about how GPs and community nurses from two different organisations cared for her mother towards the end of her life.
NHS in England
Oct 2024
P-003105 — Herefordshire and Worcestershire Integrated Care Board
Mr F complains Herefordshire and Worcestershire Integrated Care Board (the ICB) wrongly removed his father-in law’s fast track funding on 13 June 2023 before he died in August. Mr F says the ICB did not follow the correct process when carrying out this review.
NHS in England
Nov 2024
P-003132 — North East London Integrated Care Board
Mr A complains about the ICB's implementation of his mother's personal health budget.
NHS in England
Partly Upheld
Nov 2024
P-004387 — County Durham and Darlington NHS Foundation Trust
Mrs O complains about the lack of care and treatment provided to her mother at home by County Durham and Darlington NHS Trusts community nursing team before she sadly died. She also complains about a GP Practice in the Durham area and says they should have carried out blood tests …
NHS in England
Dec 2025
P-004740 — Hampshire Hospitals NHS Foundation Trust
The GP Practice did not provide face-to-face consultations. The Trust did not provide support from Macmillan nurses. The Hospice did not apply national guidelines on visiting during the Covid-19 pandemic. The Hospice interrupted visiting time. The Hospice sought to persuade Mr G to be discharged to a nursing home. The …
NHS in England
Not Upheld
Jan 2026
P-001458 — Cambridgeshire and Peterborough Integrated Care Board
Mrs O complains NHS England incorrectly reviewed the processes the Integrated Care Board followed when it decided her father was not eligible for NHS funded continuing healthcare.
NHS in England
Jul 2022
P-001513 — NHS England
Mrs L complains that NHS England’s Independent Review Panel upheld Lancashire and South Cumbria Integrated Care Board’s decision that her mother was not eligible for continuing healthcare funding.
NHS in England
Aug 2022
P-001520 — Nottingham and Nottinghamshire Integrated Care Board
Mr P complains that the ICB refuses to retrospectively assess a continuing healthcare funding application.
NHS in England
Aug 2022
P-001607 — Hull University Teaching Hospitals NHS Trust
Ms T complains Hull University Teaching Hospitals NHS Trust discharged her mother, Mrs K, without a care plan and did not tell the GP or social services about the discharge.
NHS in England
Nov 2022
P-001691 — NHS England
Mrs O complains about NHS England’s Independent Review Panel (IRP). On 9 March 2021, the IRP upheld the Integrated Care Board’s (ICB's) decision that her mother was not eligible for continuing healthcare funding (CHC) between August 2014 and January 2016.
NHS in England
Nov 2022
P-001834 — NHS England
Dr U complains on behalf of his father, Mr U, about NHS England’s Independent Review Panel's decision that Mr U was not eligible for Continuing Healthcare (CHC) funding. Dr U is unhappy with the IRP's process as it did not include a clinician. He feels the IRP ignored evidence.
NHS in England
Nov 2022
P-001696 — NHS England
Ms O complains about NHS England's Independent Review Panel (IRP) decision that her mother-in-law was not eligible for continuing healthcare (CHC) funding.
NHS in England
Dec 2022
P-001681 — NHS England Midlands and East
Mrs N complains about NHS England’s decision not to hold an Independent Review Panel (IRP) when considering whether her mother was eligible for continuing healthcare (CHC) funding for the period of 26 January 2012 to 19 August 2014.
NHS in England
Dec 2022
P-001744 — NHS England
Ms L complains about an NHS England decision regarding NHS continuing healthcare for her mother.
NHS in England
Jan 2023
P-001716 — Birmingham and Solihull Integrated Care Board
Mrs W complains the ICB will not complete a continuing healthcare retrospective review of her late mother in law’s needs for the period from 1 January 2018 to 16 July 2018.
NHS in England
Jan 2023
P-001740 — NHS England
Mrs H complains NHS England’s Independent Review Panel (IRP) did not find her mother, Mrs T, eligible for NHS funded continuing healthcare (CHC) for the period 1 April 2004 to 23 December 2011.
NHS in England
Jan 2023
P-001838 — Suffolk and North East Essex Integrated Care Board
Mr O complains the ICB refused to award continuing healthcare funding (CHC) to his wife, Mrs O. He feels that regulations were breached and assessments were carried out incorrectly, resulting in Mrs O only receiving NHS-funded Nursing Care.
NHS in England
Jan 2023
P-001787 — Humber and North Yorkshire Integrated Care Board
The legal firm complains the ICB is acting against the National Framework by refusing to do a checklist or decision support tool for Mrs A, unless instructed by the care home. It also complains the ICB has refused an appeal of the NHS-funded nursing care review in July 2020 and …
NHS in England
Feb 2023
P-002013 — Bedfordshire Hospitals NHS Foundation Trust
Mrs C complains the Trust discharged her father too soon as he was dehydrated and could not move. She also complains it did not communicate her father's needs when he was discharged, meaning they did not know how best to care for him or keep him comfortable. She says because …
NHS in England
Partly Upheld
Jun 2023
P-003858 — Black Country Integrated Care Board
Ms B complains the ICB wrongly decided not to fully assess her mother’s needs to check if she was eligible for NHS Continuing Healthcare (CHC) funding.
NHS in England
Sep 2023
P-002377 — Barts Health NHS Trust
Mr E complains about the care and treatment his mother had. He complains about her treatment, discharge and arranged care package that could not meet her needs.
NHS in England
Dec 2023
P-002695 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs N complains about aspects of care and treatment the Trust, Practice A and Practice B provided to her son, who has severe and complex health needs.
NHS in England
Jun 2024
P-002832 — United Lincolnshire Hospitals NHS Trust
Ms O complains the Trust communicated poorly with her family about her brother’s care, that it failed to provide a diet that was appropriate for his swallowing difficulties, it delayed putting a plan in place for her brother’s rehabilitation and it failed to support the family and effectively co-ordinate her …
NHS in England
Upheld
Jul 2024
P-002795 — Cornwall and Isles of Scilly Integrated Care Board
Mr O complains the Cornwall and Isles of Scilly Integrated Care Board incorrectly declined a positive Continuing Healthcare checklist completed for his mother in June 2023.
NHS in England
Jul 2024
P-002846 — NHS England
Mrs A complains about her father’s continuing healthcare (CHC) consideration by NHS England (NHSE). NHSE upheld Lancashire & South Cumbria Integrated Care Board’s decision that he was ineligible for CHC funding.
NHS in England
Aug 2024
P-003170 — NHS England
Mrs O complains about NHS England’s Independent Review Panel, which upheld South Yorkshire Integrated Care Board's decision that her daughter was not eligible for NHS Continuing Healthcare funding.
NHS in England
Nov 2024
P-003178 — NHS England
Mr N complains NHS England’s independent review panel (IRP) upheld the decision that his late mother was not eligible for NHS continuing health care (CHC) funding for the period 9 July 2016 to 1 November 2017.
NHS in England
Nov 2024
P-003407 — Cheshire and Merseyside Integrated Care Board
Mrs B complains about Cheshire and Merseyside Integrated Care Board (ICB) on behalf of her late mother, Mrs C. She says the ICB did not acknowledge and apply the COVID-19 emergency legislation.
NHS in England
Nov 2024
P-003201 — Greater Manchester Integrated Care Partnership
Mrs M complains about Greater Manchester Integrated Care Board’s (ICB) decision not to conduct a full assessment of her mother's eligibility for continuing healthcare (CHC) funding after completing a checklist on 16 May 2019.
NHS in England
Upheld
Dec 2024
P-003181 — A practice in the Newham area
Mr B complains the poor standard of nursing care Barts Health NHS Trust provided to his father in October 2023 caused him to suffer pain and hastened his death.
NHS in England
Dec 2024
P-003316 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr and Mrs D complain about the care the Trusts gave to their father in January and February 2022. They say he was discharged without appropriate care and support being arranged.
NHS in England
Partly Upheld
Feb 2025
P-003349 — Mid and South Essex NHS Foundation Trust
Mrs I complains about the Trust's care and treatment of her husband in August and September 2022. She says staff did not provide adequate nutrition and hydration, they did not make sure he participated in physiotherapy and they discharged him when he was not ready.
NHS in England
Partly Upheld
Feb 2025
P-003478 — Midlands Partnership University NHS Foundation Trust
Ms A complains about the care provided to her mother in November and December 2022. She complains about the decision to put her mother on end-of-life care, the medication given, not getting input from the Parkinsons team and poor communication with the family.
NHS in England
Apr 2025
P-003479 — Isle of Wight NHS Trust
Mrs F complains the Isle of Wight Trust did not communicate her husband’s diagnosis and transferred him to Portsmouth Hospitals Trust before she could see him. She complains Portsmouth Hospitals Trust failed to provide appropriate care on his admission and did not communicate his death to her in a timely …
NHS in England
Apr 2025
P-003543 — University Hospitals of North Midlands NHS Trust
Miss A complains she was unsafely discharged from the Trust on 3 August 2022 with an open wound in her neck. Miss A says the Trust also failed to refer her to the district nursing service when she was discharged.
NHS in England
May 2025
P-003576 — Nottingham University Hospitals NHS Trust
Mr B complains the Trust sent his wife home with a brain aneurysm. He also says his wife was wrongly moved to a low dependency ward and communication about his wife’s condition was poor.
NHS in England
May 2025
P-003619 — West Yorkshire Integrated Care Board
Ms P complains the ICB did not fund an adequate package of care for her mother, Mrs J. Ms P complains about the care a specialist respiratory team provided to her mother, Mrs J. She also complains about her mother’s care during a hospital admission before she died.
NHS in England
Partly Upheld
Jun 2025
P-003787 — Norfolk and Waveney Integrated Care Board
Mr and Mrs A complain that Mrs A was unable to access urgent eyecare when they were on holiday.
NHS in England
Aug 2025
P-003797 — Greater Manchester Integrated Care Partnership
Mrs C complains about the ICB's handling of her father's continuing health care package.
NHS in England
Aug 2025
P-003796 — North East and North Cumbria Integrated Care Board
Mrs B complains on behalf of her and her sister, Miss C, about how the ICB handled her continuing healthcare (CHC) care package in December 2022.
NHS in England
Partly Upheld
Aug 2025
P-003926 — NHS England Midlands and East
Mrs O complains about the outcome of the Independent Review Panel on 25 March 2024 to consider the integrated care board’s decision that her mother was not eligible for NHS continuing healthcare (CHC) funding.
NHS in England
Sep 2025
P-004005 — NHS England
Mr K complains that NHS England’s independent review panel (IRP) upheld the local integrated care board’s decision that his mother, Mrs V, was not eligible for NHS continuing healthcare (CHC).
NHS in England
Sep 2025
P-004086 — University Hospitals Sussex NHS Foundation Trust
Mrs U complains about the care and treatment the Trust provided to her husband from December 2021 to January 2022. She says during her husband's hospital admission, the Trust failed to appropriately manage his ongoing conditions and communication was poor.
NHS in England
Partly Upheld
Sep 2025
P-004168 — Midlands Partnership University NHS Foundation Trust
Miss R complains about the care and treatment her father received for pressure sores from a hospital, district nurses and a GP Practice.
NHS in England
Partly Upheld
Oct 2025
P-004126 — Lincolnshire Partnership NHS Foundation Trust
Mrs I complains about the care and treatment provided to her son Mr I from 2011 to 2023. Mrs I complains her son did not get the appropriate treatment for his heart condition or mental health support.
NHS in England
Oct 2025
P-004222 — Nottingham and Nottinghamshire Integrated Care Board
Mrs A complains about the ICB consideration of her mother, Mrs I, for funding. She specifically complains a funded nursing care (FNC) review in September 2022 should have led to a full continuing healthcare funding (CHC) Decision Support Tool (DST) assessment. Also the ICB incorrectly refused to carry out a …
NHS in England
Nov 2025
P-004277 — An independent provider in the City of Plymouth …
Mr R complains Livewell Southwest failed to act in a timely manner on a referral to remove his catheter or communicate with him about his needs.
NHS in England
Nov 2025
P-001085 — Southend University Hospital NHS Foundation Trust
Mrs A complains about delays in the Trust treating her husband’s sepsis. She also complained there was poor communication with her about her husband’s condition.
NHS in England
Upheld
Jul 2021
LGO / SPSO Decisions (390)
18-006-752d — NHS West Yorkshire Health and Care Partnership Integrated …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
18-006-752c — NHS West Yorkshire Health and Care Partnership Integrated …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-006-652a — NHS South West London ICB (21 006 652a)
Summary: Mrs B complains about the ICB’s funding of her disabled son F’s care. She says the ICB did not fund enough care hours, so the Council paid for extra overnight care which meant it would not increase the respite hours for her and her son. Mrs B says this …
LGO (Local Government & …
Health
Upheld
Dec 2022
22-009-742 — West Northamptonshire Council
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-008-538 — Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-014-250 — London Borough of Wandsworth
Summary: Mrs X complained the Council failed to act when she contacted it with concerns about her late brother’s care and it was difficult to get in contact with anyone. She also complained the care home the Council commissioned failed to get an air mattress for her late brother before …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
25-005-077 — London Borough of Hammersmith & Fulham
LGO (Local Government & …
Adult Care Services
Upheld
25-008-975a — NHS Hampshire and Isle of Wight ICB (25 …
LGO (Local Government & …
Health
Upheld
PSOW-202201680 — Cardiff and Vale University Health Board
Ms X complained that she was encountering concerns with her mental health team and that although she has put complaints forward to the Health Board, she is yet to receive a response. The Ombudsman was concerned that Ms X had yet to receive a response from the Health Board and …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202502982 — Aneurin Bevan University Health Board
Mr H complained that Aneurin Bevan University Health Board failed to respond to complaints submitted in December 2023 and September 2024. He also complained that it failed to communicate directly with his advocate. The Ombudsman found that there was a significant delay with the Health Board issuing the complaint responses. …
PSOW (Public Services Om…
Health
Sep 2025
20-005-428 — London Borough of Brent
Summary: Miss Y complained on behalf of her mother, Mrs X. She said the Council failed to effectively communicate with its contractor to provide her mother with a high back chair to meet her needs. Miss Y said that this resulted in Mrs X using an unsafe chair for longer …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-002-940 — Suffolk County Council
Summary: Mr X complained the Council changed and suspended his son, Mr Y’s, direct payments during 2020 without adequate communication or explanation. The Council was at fault for failing to pay Mr Y’s respite payment since 2020 despite it being an assessed care and support need. The Council agreed to …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-010-965 — Devon County Council
Summary: Ms X complains the Council delayed in reviewing Ms Y’s care plan following an increase in the hourly rate of her care provider. The Council is at fault as it delayed in carrying out a review of Ms X’s care plan and making a decision on whether to increase …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-006-660 — Essex County Council
Summary: Mr X complained the Council failed to fix a specially adapted toilet in his home after a care worker broke it several months ago. He said this situation has caused him stress and inconvenience. there was fault in the Council’s failure to source a plumber to visit Mr X’s …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-003-302 — Hampshire County Council
Summary: Mr R, representing his daughter, Ms G, said the Council was at fault for delays in providing suitable care for Ms G, and for being unhelpful and obstructive in the way it monitored spending of direct payments made to fund that care. He also said it was responsible for …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-003-925 — Peterborough City Council
Summary: We found fault with the Trust; it did not allocate Mr Q a new care coordinator, did not conduct a S117 review or formally discharge him, and it was not clear with Mr P during the complaints process. We also found the Council did not understand the care package …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
22-004-321 — City of Doncaster Council
Summary: We will not investigate this complaint about the Council’s handling of Mr X’s direct payments. This is because there is insufficient evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-005-829a — Warrington & Halton Hospitals NHS Foundation Trust (21 …
Summary: Mrs B complains about what happened when her father, Mr C, was discharged from hospital after attending with a fractured collarbone, and about arrangements for putting a care package in place. We found the Trust was at fault for the lack of information given to Mr C and his …
LGO (Local Government & …
Health
Upheld
Sep 2022
22-007-883 — Leicester City Council
Summary: We will not investigate this complaint the Council delayed in arranging for Mr X’s property to be decluttered. That is because we are satisfied with the action the Council proposes to take.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
21-013-224b — NHS Lincolnshire ICB (21 013 224b)
Summary: Mrs B complained about the health and social care support provided by the Council and the NHS Trust after she removed her late husband, Mr B, from a respite placement and took him home. She also complained about the way the former Clinical Commissioning Group (CCG and now Integrated …
LGO (Local Government & …
Health
Upheld
Nov 2022
21-013-224a — Lincolnshire Community Health Services (21 013 224a)
Summary: Mrs B complained about the health and social care support provided by the Council and the NHS Trust after she removed her late husband, Mr B, from a respite placement and took him home. She also complained about the way the former Clinical Commissioning Group (CCG and now Integrated …
LGO (Local Government & …
Health
Upheld
Nov 2022
23-002-530a — NHS Greater Manchester ICB (23 002 530a)
Summary: We investigated a complaint about the care provided to Mrs A’s late brother, Mr B. We found fault with the Integrated Care Board who did not respond to Mrs A’s complaints in a timely manner, made a derogatory comment about her and interpreted her words rather than seeking clarification. …
LGO (Local Government & …
Health
Upheld
Apr 2024
23-010-321 — London Borough of Hillingdon
Summary: The Council’s failure to work in a joined-up way across its repairs and adaptations teams was fault. It should not have closed Ms Y’s adaptations case when it did. The Council has agreed to apologise, write to Ms Y about her adaptations, work with the repairs service, make a …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-014-971 — Birmingham City Council
Summary: Mrs X complained that although her mother, Mrs Y should receive assisted collections the Council has repeatedly failed to collect her household waste and recycling. Mrs X also complains that when the Council does empty Mrs Y’s bin, it does not return it correctly to Mrs Y’s property. The …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2024
23-014-013 — Trafford Council
Summary: Mr X complained the Council failed to reduce Ms Y’s care package after it was temporarily increased. The Council was at fault for increasing the package without telling Ms Y, in how it decided to increase the package, for delay reviewing it and delay progressing obtaining a hoist for …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
22-017-137 — City of Bradford Metropolitan District Council
Summary: Ms Y complained about failings during her father’s discharge planning, and delays in the repatriation of her mother. We have found fault by the Council for failings in discharge planning. We have also found fault by Bradford Trust and Chesterfield Trust for failings in the repatriation process. These faults …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2024
23-014-449 — London Borough of Newham
Summary: Ms X complained about the way the Council handled her request for housing assistance and how it responded to her concerns about the condition of her property. As a result, Ms X lived in a property with repair issues and this impacted her health. We have found the Council …
LGO (Local Government & …
Housing
Upheld
Aug 2024
24-000-008 — London Borough of Ealing
Summary: Mrs Y complained the Council failed to arrange suitable care for her mother, Mrs X, when she was discharged from hospital. Mrs Y said this meant she and her sister, Ms W, had to provide the care instead. The Council was at fault for delay in arranging a new …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
24-000-025 — London Borough of Newham
Summary: We upheld Ms X’s complaint. There was a delay in assessing her son Mr Y’s social care needs and her need for support in her caring role. There was also a delay in agreeing funding for a day centre placement. The outcome and recommendations of assessments were confusing. The …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
23-017-874a — Norfolk & Norwich University Hospitals NHS Foundation Trust …
Summary: We found fault with the care and support provided to Mr Y by the Council as it failed to properly assess his needs in the community. This caused Mr Y’s daughter, Mrs X, significant frustration and distress. The Council will apologise to Mrs X and pay her a financial …
LGO (Local Government & …
Health
Not Upheld
Sep 2024
23-019-435 — West Sussex County Council
Summary: Mrs X complained about the Council’s decision to remove transport funding from Mr X’s care package and about its complaints handling. We found fault in the Council’s decision making and complaint handling which caused Mrs X and her family distress and frustration. To put matters right, the Council agreed …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
24-018-121 — Dorset Council
Summary: We will not investigate this complaint about the Council’s actions during the assessment for NHS funding for adult care. The Council’s actions do not cause the claimed injustice of a failure to award Continuing Healthcare funding. That is an NHS decision, and is not an outcome the Council nor …
LGO (Local Government & …
Adult Care Services
Apr 2025
24-004-911 — Somerset Council
Summary: Mr X complained about the Council’s handling of his son, Mr Y’s, case after he made a referral to Adult Social Care Services in March 2023. He said Mr Y has had seven allocated social workers since March 2023 which delayed Mr Y getting the relevant care assessments and …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-002-649 — Birmingham City Council
Summary: Mr X complained about delays in the Council completing adaptations to his home following an Occupational Therapy assessment in January 2023. Mr X said this caused him significant distress and he suffered physically. There was fault in the way the Council delayed completing the work to Mr X’s home, …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
23-013-609b — Royal Free London NHS Foundation Trust - North …
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …
LGO (Local Government & …
Health
Upheld
Jun 2025
23-013-609a — Royal Free London NHS Foundation Trust - North …
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …
LGO (Local Government & …
Health
Upheld
Jun 2025
24-016-885 — Kirklees Metropolitan Borough Council
Summary: Mr X complained about the Council’s decision to end direct payments to his relative Mr Z. There was no fault in the way the Council reached its decision. There was fault in its communication with Mr Z and in its failure to ensure there was a proper coordinated handover …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
24-009-941a — Somerset NHS Foundation Trust - Musgrove Park Hospital …
Summary: Mrs A complained about the care Somerset Council and Somerset NHS Foundation Trust provided to her daughter, Miss B, before her death. She complains the Council and Trust refused to provide funding for 24-hour care which Miss B needed, could not find Miss B a suitable care agency and …
LGO (Local Government & …
Health
Not Upheld
Oct 2025
24-009-941 — Somerset Council
Summary: Mrs A complained about the care Somerset Council and Somerset NHS Foundation Trust provided to her daughter, Miss B, before her death. She complains the Council and Trust refused to provide funding for 24-hour care which Miss B needed, could not find Miss B a suitable care agency and …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2025
25-009-306 — Sandwell Metropolitan Borough Council
Summary: We will not investigate this complaint about the care and support the Council provided to the complainant’s neighbour following their discharge from hospital. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Nov 2025
24-010-479 — Gravesham Borough Council
Summary: We cannot investigate some of Ms X’s complaints about anti-social behaviour from a neighbour as they relate to the Council’s role as a social landlord and the law says we cannot investigate. We will not investigate other elements of Ms X’s complaint because an investigation is unlikely to achieve …
LGO (Local Government & …
Environment And Regulation
Nov 2024
201503727 — Falkirk Council
Ms C's mother was admitted to a care home and the council provided Ms C's family with a breakdown of the charges for the care home and invoiced the family accordingly. Following an admission to hospital, Ms C's mother returned to the care home, however, Ms C's family received no …
SPSO (Scottish Public Se…
Local Government
Upheld
Mar 2016
25-006-991a — East London NHS Foundation Trust (25 006 991a)
Summary: Mr C complains the Council and Trust failed to provide him with suitable care, respond to calls, and support him with his direct payments. We will not investigate the complaint as some of the complaints are late. The Council has acted to remedy other complaints and complete a new …
LGO (Local Government & …
Health
Dec 2025
201809536 — Argyll and Bute Health and Social Care Partnership
Mr and Mrs C complained about the partnership's management of their adult son's care (Mr A). Mr A's care was managed by the partnership for a number of years. The partnership moved Mr A's care away from his family base when they came to the view that the level of …
SPSO (Scottish Public Se…
Health and Social Care
Partly Upheld
Mar 2020
202302196 — Orkney NHS Board
C complained that the board failed to provide reasonable physiotherapy care and treatment to their child (A) and failed to maintain reasonable clinical records. We took independent advice from a physiotherapist. We found that some aspects of A’s care were reasonable, particularly in relation to ongoing treatment at school, and …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2024
PSOW-202105742 — Betsi Cadwaladr University Health Board
Mrs J complained about the actions of the Learning Disability Team (“the LD Team”) of the Health Board in response to her request to provide assistance to move her sister, Miss M, from the upstairs of her home to a new home with Mrs J and her family in April …
PSOW (Public Services Om…
Health
Upheld
Dec 2022
PSOW-202101741 — Aneurin Bevan University Health Board
Mr A’s concerns related to the treatment and care of his late wife, Mrs A. He complained about his wife’s care during her inpatient admission at the Royal Gwent Hospital (“the Hospital”) between 15 March and 31 March 2020, the accuracy of his wife’s clinical records and the Health Board’s …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202307690 — Aneurin Bevan University Health Board
Ms G complained that Aneurin Bevan University Health Board had failed to respond to the complaint she had made to it in May 2023. The Ombudsman found that there was a delay in the Health Board responding to Ms G’s complaint, which the Ombudsman said caused frustration to Ms G. …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202307628 — A Dental Practice in the area of Swansea …
Miss X complained that a Dental Practice in the area of Swansea Bay University Health Board had failed to respond to her complaint about being deregistered from the Practice. Miss X had made her complaint in September 2023. The Ombudsman found that the Practice had failed to respond to Miss …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202307183 — Betsi Cadwaladr University Health Board
Mrs A complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint until her MP raised the concerns on her behalf. The Ombudsman found that the Health Board had initially responded to Mrs A’s concerns informally. However, following the same concerns being raised by Mrs …
PSOW (Public Services Om…
Health
Jan 2024