Significant event log failures
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
120 items
10 sources
8 inquiries
Source spread
Where this theme appears
Significant event log failures has been flagged across 10 independent accountability sources:
32 inquiry recs
9 PFD reports
1 committee rec
27 CQC actions
19 IMB recs
10 Article 2 learning points
1 detention investigation rec
8 PHSO decisions
8 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 (32)
F99 — National Patient Safety Agency functions
Recommendation: The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.
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
F98 — National Patient Safety Agency functions
Recommendation: Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.
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
COVID-M1.6 — Triennial Pandemic Exercises
Recommendation: The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.4 — UK-wide Civil Emergency Strategy
Recommendation: The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. The strategy should: be adaptable; include sections dedicated to …
Gov response: No formal response published by this government.
Accepted in Part
In progress
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: Department for Business and Trade acknowledges this recommendation and sees clear advantages in establishing a standing public body for financial redress. However, the government recognises that establishing such an independent redress body requires careful consideration …
Response Unclear
In progress
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: Department for Business and Trade rejects this recommendation as it conflicts with the principle of providing "full and fair" redress. Postmasters should retain the choice between continuing with the dispute resolution procedure or transferring to …
Not Accepted
MAI-152 — Recording equipment for incident commanders
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that all those who may be required to take up a command position in the event of a Major Incident are …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-84 — Review NWFC incident log information storage
Recommendation: North West Fire Control should review the way it captures and records key information on its incident logs in order to ensure that the information is stored in one place and is readily accessible at all times by those who …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-81 — Improve NWFC Major Incident record-making
Recommendation: North West Fire Control should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-71 — Improve NWAS Major Incident record-making
Recommendation: North West Ambulance Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-38 — Improve GMP Major Incident record-making
Recommendation: Greater Manchester Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-33 — Improve GMFRS Major Incident record-making
Recommendation: Greater Manchester Fire and Rescue Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-19 — Provide recording equipment to control room personnel
Recommendation: Consideration should also be given by those organisations to the provision of such equipment to key personnel within control rooms.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-14 — Improve BTP Major Incident record-making
Recommendation: British Transport Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
F100 — National Patient Safety Agency functions
Recommendation: Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.
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
12 — Review incident investigation structures
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements …
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
IHRD-31 — SAI Reporting Understanding
Recommendation: Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
Gov response: SAI reporting training provided to healthcare professionals across Trusts.
Accepted
IHRD-17 — Recording Changes in Accountability
Recommendation: Any change in clinical accountability should be recorded in the notes.
Gov response: Incorporated into clinical documentation standards.
Accepted
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
25 — Duty to report external investigation findings
Recommendation: We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external …
Gov response: 43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, …
Accepted
23 — Clear standards for incident reporting in maternity
Recommendation: Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there …
Gov response: 23. We accept this recommendation in principle. A new national, Independent Patient Safety Investigation Service will supplement existing practice. 24. The Investigation found that there were a substantial number of missed opportunities to uncover and …
Accepted
CLAR-3 — Remind agencies to keep detailed, accurate records, especially mortuary documentation
Recommendation: We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.
Unknown
IHRD-70 — Board Meeting Minutes Preservation
Recommendation: Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
Gov response: Board and committee meeting minutes preservation procedures strengthened.
Accepted
IHRD-48 — Mortality Meeting Recording and Audit
Recommendation: The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Gov response: Mortality meeting recording and audit procedures implemented.
Accepted
IHRD-45 — Post-Mortem Documentation Checklist
Recommendation: Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
Gov response: Checklist protocols developed for hospital post-mortem documentation.
Accepted
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes. Patient Advocacy Service being developed.
Accepted
No update 2+ yrs
IHRD-32 — SAI Reporting as Disciplinary Offence
Recommendation: Failure to report an SAI should be a disciplinary offence.
Gov response: Incorporated into Trust disciplinary policies.
Accepted
11 — Raise awareness of incident reporting and duty of candour
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with …
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
IHRD-29 — Record Keeping Audit
Recommendation: Record keeping should be subject to rigorous, routine and regular audit.
Gov response: Record keeping audit programmes established across Trusts.
Accepted
IHRD-24 — Blood Test Result Documentation
Recommendation: All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Gov response: Blood test documentation standards updated. Serum sodium recording on fluid balance charts implemented.
Accepted
SHI-4 — Standard form for derogations from guidance
Recommendation: The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
PFD Reports (9)
Elsie May Treece
Concerns: Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Response (Burton Hospitals NHS): Burton Hospitals NHS has always provided training for staff in relation to incident reporting, and they have arranged to provide additional training and support for Ward 6. They have linked …
Responded
Thomas Burchell
Concerns: Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.
Response (The Borchardt Medical centre): The practice changed its policy so staff must add a code to computerised records the same day they arrive, alerting clinicians. A clinical meeting reviewed NICE and local guidelines for …
Overdue
Matthew Gunn
Concerns: An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
Response (Morrisons): Morrisons will issue a bulletin to stores instructing employees to report observed epileptic events to a first aider. They will update first aid training and policy, and record epileptic events …
Overdue
Janet Hall
Concerns: The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend analysis.
Overdue
Julie Morrey
Concerns: A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.
Response (University Hospitals of North Midlands NHS Trust): University Hospitals of North Midlands NHS Trust has implemented actions including increasing the frequency of safety huddles, assuring that senior matrons are aware of patients requiring speciality input, staffing senior …
Responded
Eileen Pollard
Concerns: Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Overdue
Vivien Brunning
Concerns: Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Response (Croft Shifa Health Centre): The practice held a meeting to discuss patient documentation workflow, agreeing that all DNA and Bardoc visit notifications will be date stamped and forwarded to the addressed GP; the amended …
Overdue
Chloe Every
Concerns: The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Response (Barking Havering and Redbridge NHS Foundation Trust): The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability. In July 2024, the Learning Review …
Response (Department of Health and Social Care): NHSE have informed the DHSC that BHRUT is preparing a response to address the coroner's concerns in full. Daily checks are conducted by the Learning Disability Team at the Emergency …
Responded
Richard Moss
Concerns: Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Response (Townhead Surgery): Townhead Surgery describes developing its own internal safety system involving a reporting system to search for unsent Rapid Access Chest Pain Referrals, running the report every two weeks. They also …
Response (Townhead Surgery Update): Townhead Surgery reports that the ICB has modified the chest pain referral pathway so that it is no longer possible to complete a referral without simultaneously sending a message to …
Responded
CQC Inspection Actions (27)
The Peter Gidney Neurodisability Centre
The home was not notifying CQC or the funding authorities of significant events.
Must Do
Meadow Green
The provider must ensure that notifications of other incidents are made to CQC in line with Regulation 18 (2) (e).
Must Do
The Lodge Care Home
Notifications of other incidents
Must Do
Ashbourne House - Torquay
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.
Must Do
TerraBlu Homecare
Registered persons had failed to notify CQC in a timely manner about incidents that had occurred.
Must Do
Ability Associates Limited - 77 The Street
The registered manager had not ensured they notified the Care Quality Commission of allegations of abuse and incidents reported to the police.
Must Do
Fairglen Residential Home
The provider must inform CQC of notifiable events.
Must Do
Dr French Memorial Home Limited
Notifications of other incidents
Must Do
Benedict House Nursing Home
The provider must ensure that the Care Quality Commission is notified of any allegation of abuse in relation to a person using the service.
Must Do
Universal Care - Beaconsfield
The provider failed to ensure it notified us of events it was legally responsible to inform us.
Must Do
Universal Care - Beaconsfield
The provider failed to ensure they notified us when changes occurred.
Must Do
The Newcastle Clinic
The service should have a system to identify, record, review and report incidents.
Should Do
TerraBlu Homecare
One person had fallen and injured themselves in January 2022 and had been found by a staff member. This had not been appropriately recorded.
Should Do
Percys Travel
The service did not ensure that incidents were reported and shared effectively by staff and managers in line with the full scope of their policy.
Must Do
Bousfield Surgery
Improve the management of significant events and complaints by providing appropriate training to the person responsible for the investigation and documentation of significant events and complaints.
Should Do
Billet Lane Medical Practice
Takeactiontorecordthereviewsofsignificanteventsatclinicalmeetingsandcompleteasignificanteventlog.
Should Do
Ashville House
Records of incidents, accidents and falls were not fully collated, showing the level of impact or lessons learnt.
Should Do
The Homestead (Crowthorne) Limited
The registered person failed to notify the Commission of notifiable events, 'without delay'.
Must Do
St Clare's Hospice
The provider must develop robust incident management processes, to ensure all incidents are reported, investigated and lessons learnt following incidents are shared.
Must Do
Alde House
We recommend that the provider reviews the documentation completed by the management team following incidents and accidents.
Should Do
Yanah Care
The provider should seek support with recording and monitoring the service.
Should Do
M N Pulse Solutions
improvement was needed to the records maintained such as to include dates and full detail about the incident and investigation.
Must Do
Donnington House Care Home
Processes were not in place to ensure management oversight of accidents and incident records. The registered manager told us they did not have oversight of accidents and incidents and were not aware of any processes to identify trends, drive service …
Should Do
Cherished Moments
The service must ensure equipment faults and other safety incidents are reported as incidents.
Must Do
Ashville House
No immediate actions had been taken following this incident and this must be reviewed urgently.
Should Do
Melville House
The provider must ensure that all required statutory notifications are sent to CQC.
Must Do
Linda Lodge
The provider must notify CQC of other incidents.
Must Do
IMB Recommendations (19)
London STHF (2024)
The Board stopped receiving Safer Detention Reports in July 2023 and despite many requests, these have not been forthcoming. This means that we do not have access to the data to enable us to monitor Suicide and Self Harm Warning Forms, Vulnerable Adult Warning Forms and Use of Force. After repeated requests at every Board meeting, we were eventually told …
Other
Swansea (2022)
Informing the Board about Care & Separation Unit (CSU) admissions and Good Order or Discipline (GOOD) reviews in line with the Memorandum of Understanding has been inconsistent (see paragraph 5.2.6). The Board acknowledges its absence from the prison for much of the reporting year but the requirement continued during remote monitoring and its previous report also highlighted this issue.
Governor / Director
Swaleside (2022)
The IMB is concerned at the occasional failure to be invited to serious incidents and planned moves to the CSRU and would appreciate the necessity for this to be reiterated to all senior staff.
Governor / Director
Exeter (2020)
Will the Governor continue to build on improvements to notify the Board of serious and other notifiable incidents or events?
Governor / Director
Risley (2021)
There have been instances where the Board has not been called to serious incidents, particularly out of hours. What are your plans, going forward, to ensure that Board members may monitor and observe serious incidents, while maintaining all appropriate safety and security protocols?
Governor / Director
Thameside (2022)
More rigorous monitoring and analysis of cell bell data, especially data covering night-time calls, and address the system’s unreliability (see section 5.1).
Governor / Director
Wandsworth (2024)
In the past year, the IMB was not always informed of major incidents, particularly Deaths in Custody. Can you assure us that you will put a process in place to rectify this?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2024)
The Board recommends the examination and review of the low number of Rule 32/35 risk to health and risk of suicide cases, in order to check that the low number of cases is not indicative of the process failing to be used as it should be to identify those facing a deterioration of their health in detention and those at …
Home Office
Wayland (2021)
As our monitoring has revealed a significant likelihood that cell clearance certification procedures have not always been duly followed, the Board believes that the importance of managing an accurate and timely cell clearance certificate needs reinforcement on a national basis (see section 5.8).
HMPPS
Thameside (2023)
Continue to scrutinise cell bell data to improve answering times. Consider strategies to deter prisoners who repeatedly mis-use the cell bell system.
Governor / Director
Liverpool (2023)
The Board has raised several concerns about monitoring and oversight of UoF incidents. What further action will be taken to improve this area?
Governor / Director
Liverpool (2023)
The Board is not notified of all applicable incidents/events in line with the Memorandum of Understanding. In addition, the Board does not always receive the data or meeting invites as it should. What action will be taken to improve this area so the Board can monitor effectively?
Governor / Director
Isis (2023)
Can the Governor ensure that processes for making sure that cell bells are answered in the specified times are followed and monitored?
Governor / Director
Grendon (2020)
improvements in cell bell analysis and/or response times (see paragraph 4.3.7)
Governor / Director
Swinfen Hall (2023)
What action will be taken to reduce the backlog of OASys reports that impacts negatively on outcomes for prisoners?
Governor / Director
Low Newton (2023)
How can the Board work with the prison to have better oversight of adjudications, as well as GOOD reviews held in the safety and support unit?
Governor / Director
Isle of Wight (2023)
When will the Governor put in place an effective means to monitor the impact of the literacy strategy?
Governor / Director
Isis (2023)
Can the Governor ensure that data regarding separate and restricted regimes is collated and analysed to provide a better understanding of these regimes’ use and impact?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that Border Force staff at STHFs ensure that all ongoing care and welfare checks are fully and properly recorded on the annex A form in the port.
Home Office
Health Investigations (5)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 7c
A national perinatal incident repository to enable systematic learning from local and national reportable incidents.
wales
Accepted
Independent investigation into the care and treatment of Mr L — Rec 5
The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about: the type of records to be created and stored when conducting an internal investigation; storage and retrieval of clinical records, and reporting of misplaced clinical records, …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
An independent review of the Independent Investigations for Mental Health … — Rec 7
It is recommended that the IIGC should develop additional metrics and key performance indicators to provide assurance of regional adherence to quality as well as process requirements of Independent Investigations and the Serious Incident Framework.
north_east_yorkshire
Independent investigation into the care and treatment of Mr L — Rec 5
The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about: the type of records to be created and stored when conducting an internal investigation; storage and retrieval of clinical records, and reporting of misplaced clinical records, …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 7b
A specialist sub-committee of the National Strategic Oversight Board should oversee Health Boards' delivery of the perinatal National Reportable Incident process, ensure timely, multidisciplinary and family-centred responses, and produce national thematic learning.
wales
Accepted
Article 2 Learning Points (10)
— LP 7
NOMS may wish to consider whether the introduction and use of bespoke bound notebooks would be appropriate for use by personnel engaged in the management of serious or critical incidents. Similar documents are in use in other organisations for the purpose of recording, in one place, notes, thought processes and …
NOMS
Accepted
— LP W
A clearer policy should be developed about the nature and extent of investigations which should take place following incidents of self-harm, so that prisons know when a local investigation within the prison is likely to be adequate, when an internal Prison Service investigation by the Area Manager is needed and …
HMPPS
— LP 12
We recommend that clearer guidance is produced on what kind of immediate internal inquiry should be undertaken following acts of serious self-harm, what evidence should be collated and retained and what form of action planning should be set in place as a result.
HMPPS
Partially Accepted
— LP 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
HMP Whitemoor
Accepted
— LP 2
If they have not already done so, NOMS and HMP Whitemoor should consider if current procedures and staff training provide for the full and accurate completion of official prison documents. Adequate audit and storage arrangements should also be considered as part of any subsequent review. The investigation highlighted a high …
NOMS and HMP Whitemoor
Accepted
— LP 6
Archived records in accordance with PSO 9020 should be more clearly indexed to facilitate future investigations.
HMPPS
— LP V
When a case of near death occurs, the scene, documentation and any files should be secured in the same way as follows a death.
HMPPS
— LP U
In cases of near death or serious injury, the Governor should initiate an investigation as a matter of urgency, securing all relevant documents and evidence.
The Governor
— LP J
Managers must ensure that any downgrading in Cell Sharing Risk Assessment is documented correctly, giving valid reasons for any decision.
HMPPS
Accepted
— LP I
Cell moves in F Wing should be better documented and countersigned by management. If prisoners are moved for their safety and wellbeing, this should be noted in their prison files and ACCT document.
HMPPS
Rejected
PHSO Casework Decisions (8)
P-002443 — Hull University Teaching Hospitals NHS Trust
Ms F complains that her daughter had to wait for over 30 hours before being moved to intensive care, that the Trust failed to find the cause of her bleeding and treat it, and that it did not accurately record the cause of her death.
NHS in England
Feb 2024
P-004303 — King's College Hospital NHS Foundation Trust
Mrs F complains that the Trust discharged her son Mr F when it shouldn't have done and did not communicate with her about this discharge sufficiently. She also complains about the Trust's protracted complaints procedure and its failure to record Mr F's death as a serious patient safety incident until …
NHS in England
Upheld
Nov 2025
P-002460 — Surrey and Sussex Healthcare NHS Trust
Ms I complains about the care and treatment her father had from the Trust between December 2021 and January 2022.
NHS in England
Partly Upheld
Feb 2024
P-002471 — King's College Hospital NHS Foundation Trust
Ms J complains that the Trust used the wrong arm to draw blood and insert a drip line, failed to report this as an incident and let her catheter overfill.
NHS in England
Feb 2024
P-002479 — Manchester University NHS Foundation Trust
Miss R complains about the care given to her father before his sudden death in December 2022.
NHS in England
Feb 2024
P-002769 — Northern Care Alliance NHS Foundation Trust
Mrs E complained the Trust did not have an adequate surveillance plan in place following her care and treatment for cancer in April 2021 and delayed in acting upon the results of a scan carried out in June 2022.
NHS in England
Partly Upheld
Jul 2024
P-004456 — Portsmouth Hospitals University NHS Trust
Ms N complains the Trust did not identify, record and treat complications that arose during Mr L’s procedure in September 2022.
NHS in England
Dec 2025
P-004487 — University Hospitals Sussex NHS Foundation Trust
Mr Y has concerns that his mother experienced a fall at the Trust and subsequently died. Mr Y was also concerned about the Patient Safety Incident Investigation
NHS in England
Dec 2025
LGO / SPSO Decisions (8)
21-010-289 — Sheffield City Council
Summary: Miss H complains the Council and Trust significantly delayed her son J’s Education, Health and Care Plan annual review, and J did not receive the 1-1 speech and language therapy sessions in his plan. There was fault by the Council and Trust. There were long delays in the annual …
LGO (Local Government & …
Education
Upheld
Aug 2022
25-003-138 — Suffolk County Council
Summary: The Council was at fault. It did not issue Mrs X’s child, Y’s, decision letter or Education, Health and Care (EHC) Plan within the statutory timescales after Y’s late January 2025 annual review. It also communicated poorly with Mrs X. The symbolic payment the Council has already offered to …
LGO (Local Government & …
Education
Upheld
Dec 2025
25-001-155 — West Northamptonshire Council
Summary: Miss X complained the Council failed to adhere to the statutory timeframes for issuing her child, Z’s, Education, Health and Care Plan, and it failed to provide Z with access to suitable education. We find the Council at fault for a delay in issuing a final Education, Health and …
LGO (Local Government & …
Education
Upheld
Dec 2025
24-023-490 — Cheshire West & Chester Council
Summary: The Council is at fault for poor communication and delay in the annual review process, causing distress. It also failed to provide education. The Council has accepted it is at fault and provided a suitable remedy.
LGO (Local Government & …
Education
Upheld
Dec 2025
25-000-070 — Walsall Metropolitan Borough Council
Summary: I find fault and delay by the Council in securing special educational provision. Z has missed out on specialist therapy and other support for over two terms. This is an injustice. The Council has agreed to apologise, make a symbolic payment and service improvements. The complaint is upheld.
LGO (Local Government & …
Education
Upheld
Dec 2025
24-022-210 — Somerset Council
Summary: We have found the Council at fault for its delay in issuing a final amended Education, Health and Care Plan for Miss X’s son, Y ahead of his transfer to post-16 education. This resulted in Miss X and Y suffering avoidable distress. We have also found the Council at …
LGO (Local Government & …
Education
Upheld
Dec 2025
201709143 — Fife NHS Board
Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity). Mr C complained that the service refused to offer him bariatric …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2021
25-002-113 — Lancashire County Council
Summary: Mrs B complained the Council has failed to update her son’s Education, Health and Care (EHC) Plan since the first annual review and its communication with her has been poor. There was fault by the Council. It did not meet statutory timescales during the annual review process and issuing …
LGO (Local Government & …
Education
Upheld
Jan 2026