Staff policy awareness
133 items
2 sources
Absence of a system to confirm that all staff have read and understood existing, updated, or new policies, procedures, and guidance documents.
Cross-Source Insight
Staff policy awareness has been flagged across 2 independent accountability sources:
65 inquiry recs
68 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (65)
BAHA-18 — Whistleblower Protection
Recommendation: JDP 1-10 should address the protection that will be afforded to service personnel who make complaints or allegations in good faith of the mistreatment of CPErS. It should give guidance as to those who can be approached when service personnel …
Gov response: Accepted. Guidance on protection for those reporting mistreatment and appropriate contacts has been included.
Accepted
Delivered
BAHA-2 — Standard Orders Prohibiting Five Techniques
Recommendation: Joint Doctrine Publication (JDP) 1-10 should include the requirement for standard orders to be issued for each operation prohibiting the use of the five techniques.
Gov response: Accepted. JDP 1-10 has been updated to require standard orders prohibiting the five techniques for each operation.
Accepted
Delivered
BAHA-23 — Ban Harsh Approach in Tactical Questioning
Recommendation: The harsh approach should no longer have a place in tactical questioning. The MoD should forbid tactical questioners from using what is currently known as the harsh approach and this should be made clear in the tactical questioning policy and …
Gov response: Not accepted. The Defence Secretary decided not to accept this recommendation. The MoD retained the ability to use the harsh approach in tactical questioning, subject to strict parameters and safeguards.
Not Accepted
BRIS-11 — NHS employers must ensure staff allow patients time for questions
Recommendation: Patients should always be given the opportunity and time to ask questions about what they are told, to seek clarification and to ask for more information. It must be the responsibility of employers in the NHS to ensure that the …
Unknown
BRIS-23 — Endorse and implement DoH consent guide across all NHS healthcare professional practice
Recommendation: We note and endorse the recent statement on consent produced by the DoH: ‘Reference guide to consent for examination or treatment’, 2001. It should inform the practice of all healthcare professionals in the NHS and be introduced into practice in …
Unknown
BRIS-43 — Redefine trust-consultant contracts to specify resources and explicit work commitments
Recommendation: The contractual relationship between trusts and consultants should be redefined. The trust must provide the consultant with the time, space and the necessary tools to do the job. Consultants must accept that the time spent in the hospital and what …
Unknown
BRIS-45 — Incorporate doctors' professional practice code into employment contracts and GP terms
Recommendation: The doctors’ Code of Professional Practice, as set down in the GMC’s ‘Good Medical Practice’, should be incorporated into the contract of employment between doctors and trusts. In the case of GPs, the terms of service should be amended to …
Unknown
BRIS-46 — Incorporate professional codes of practice into contracts for nurses, allied professions, managers
Recommendation: The relevant codes of practice for nurses, for professions allied to medicine and for managers should be incorporated into their contracts of employment with hospital trusts or primary care trusts.
Unknown
BRIS-47 — Enable trusts to independently address healthcare professional code breaches
Recommendation: Trusts should be able to deal as employers with breaches of the relevant professional code by a healthcare professional, independently of any action which the relevant professional body may take.
Unknown
BRIS-53 — Develop a standard NHS job description for non-executive directors
Recommendation: A standard job description should be developed by the NHS for non-executive directors, as proposed in ‘The NHS Plan’.
Unknown
BRIS-57 — Prioritise non-clinical skills in healthcare professional education and development
Recommendation: Greater priority than at present should be given to non-clinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals: (cid:2) skills in communicating with patients and with colleagues; (cid:2) education about …
Unknown
BRIS-98 — Regulatory bodies to vary professional duties for full-time managers without patient care
Recommendation: The relevant professional regulatory bodies should make rules varying the professional duties of those professionals, whose registration they hold, who are in full-time managerial roles, so as to take account of the fact that, while occupying such roles, they do …
Unknown
DUNB-1 — Ensure officers receive full advance information for exercising caution during enquiries
Recommendation: Officers carrying out enquiries should be supplied in advance with full information about any known change of circumstances and any reason for exercising particular caution (para 8.9).
Unknown
DUNB-2 — Endorse enquiry officer checklists, requiring reporting of applicant suitability concerns
Recommendation: The use of checklists by enquiry officers is endorsed, subject to the need for them to be alert to and report anything which could be relevant to the suitability of the applicant or certificate holder (paras 8.10-8.11).
Unknown
FENN-105 — Ensure London Underground written communications are plain, presented well, and followed.
Recommendation: London Underground shall make sure that all its written communications are in plain English and properly presented. They must check that instructions are being followed.
Unknown
SHEE-55 — Emphasise clear orders, strict discipline, and effective communication for ship safety
Recommendation: This Court need say no more than stress the need for: (a) Clear and concise orders. (b) Strict discipline. (c) Attention at all times to all matters affecting the safety of the ship and those on board. There must be …
Unknown
SHEE-57 — Require entry of departure draughts in log books with strict enforcement
Recommendation: There should be a requirement that the departure draughts must be entered in the deck log book as well as the Official Log book. The only practical way of enforcing such a rule would be for the Department to initiate …
Unknown
SHEE-58 — Enlarge regulation to include all potentially hazardous occurrences on board ships
Recommendation: Consideration should be given to enlarging that regulation to include every occurrence which is potentially hazardous to the ship or to any person on board.
Unknown
28 — Revise Prison Service safeguarding guidance
Recommendation: The Chair and Panel note that Prison Service Instruction 08/2012, which sets out the mandatory actions for young offender institutions and secure training centres for 'maintaining a safe and secure environment', has expired. The Chair and Panel recommend that the …
Gov response: On 23 July 2019, the Ministry of Justice stated that work had begun to revise or replace Prison Service Instructions (PSIs) with 'policy frameworks'. In advance of updating PSI 08/2012, the Youth Custody Service published …
Accepted
No update 2+ yrs
38 — Government department safeguarding policy reviews
Recommendation: The Cabinet Office must ensure that each government department reviews its child safeguarding policy or policies in light of the expert witness report of Professor Thoburn. There must also be published procedures to accompany their policies, in order that staff …
Gov response: On 18 September 2020, the UK government confirmed that all government departments were aware of Professor Thoburn's report. It also stated that Civil Service HR had launched a model safeguarding policy and 'Health Check' process, …
Accepted
Delivered
39 — Political party safeguarding policies
Recommendation: All political parties registered with the Electoral Commission in England and in Wales must ensure that they have a comprehensive safeguarding policy. All political parties must also ensure that they have procedures to accompany their policies, in order that politicians, …
Gov response: On 3 July 2020, the Electoral Commission stated that given the statutory scope of its remit, introducing a requirement that the Commission should monitor and oversee compliance of the safeguarding policies of political parties would …
Accepted
No update 2+ yrs
51 — Review Catholic safeguarding policies manual
Recommendation: The Catholic Safeguarding Advisory Service should review its policies and procedures manual and the documents within it to ensure that they are consistent, easier to follow and more accessible.
Gov response: In November 2021, the Catholic Safeguarding Standards Agency website was launched. It contains the National Safeguarding Standards, the National Safeguarding Policy, and practice guidance documents.
Accepted
Delivered
P2-57 — Local authority review third-party contracts
Recommendation: Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This must include consideration of assurance mechanisms, such as key performance indicators, regular reporting, formal contract review meetings, site …
Gov response: This recommendation is under consideration.
Response Unclear
P2-58 — Contractual incident notification requirement
Recommendation: There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the deceased, as well as the outcome of inspections or other action by the Human Tissue Authority or others …
Gov response: This recommendation is under consideration.
Response Unclear
P2-59 — Local authority contractor governance assurance
Recommendation: Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard Operating Procedures that protect the security and dignity of the …
Gov response: This recommendation is under consideration.
Response Unclear
P2-6 — Security breaches reviewed by expert with action plans
Recommendation: All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be reviewed by a security expert who is able to identify any systemic security issues associated with the incident. …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-69 — Formalise multi-organisation arrangements
Recommendation: Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint Standard Operating Procedures. The parties to the contracts or service level agreements should ensure that …
Gov response: This recommendation is under consideration.
Response Unclear
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
Delivered
IHRD-35 — Non-Cooperation as Disciplinary Offence
Recommendation: Failure to co-operate with investigation should be a disciplinary offence.
Gov response: Incorporated into Trust investigation procedures and employment policies.
Accepted
Delivered
IHRD-4 — Trust Awareness of Duty of Candour
Recommendation: Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of healthcare.
Gov response: Reviewed in context of workforce planning. Some concerns raised by Royal Colleges about potential de-skilling impacts. Implementation being balanced against training needs.
Accepted in Part
No update 2+ yrs
IHRD-5 — Employment Contracts and Duty of Candour
Recommendation: Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
Gov response: Prototypes to determine the most appropriate way to operate such a service are progressing. Learning will inform proposals for an IME service in Northern Ireland.
Accepted
No update 2+ yrs
IHRD-52 — Inquest Duties Protocol
Recommendation: Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
Gov response: Protocols developed detailing employee duties in relation to healthcare inquests.
Accepted
Delivered
IHRD-73 — GMC Code in Employment Contracts
Recommendation: General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.
Gov response: GMC Good Medical Practice requirements incorporated into doctor employment contracts.
Accepted
Delivered
IHRD-74 — Professional Codes in Employment Contracts
Recommendation: Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.
Gov response: Professional code requirements incorporated into healthcare professional employment contracts.
Accepted
Delivered
IHRD-90 — Clinical Guidance Dissemination Protocol
Recommendation: The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to ensure accountability. (ii) The identification of specific training requirements necessary …
Gov response: Protocol development for clinical guidance dissemination progressing.
Accepted
No update 2+ yrs
LADB-34 — Reconsider the use of "disregard" in the SPAD Group Standard
Recommendation: The use of the word “disregard” in the Group Standard on SPADs and its associated documentation should be reconsidered (para 11.29).
Unknown
F10 — Fundamental standards of behaviour
Recommendation: The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health and Clinical Excellence and, where relevant, the Care Quality Commission, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F11 — Fundamental standards of behaviour
Recommendation: Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional …
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
F12 — Fundamental standards of behaviour
Recommendation: Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F178 — Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and …
Recommendation: The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly …
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
F180 — Candour about incidents
Recommendation: Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.
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
F215 — Shared code of ethics
Recommendation: A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.
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
F216 — Leadership framework
Recommendation: The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining …
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
F217 — Common selection criteria
Recommendation: A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader would be expected to have.
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
F218 — Enforcement of standards and accountability
Recommendation: Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a …
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
F219 — A regulator as an alternative
Recommendation: An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this would be greater if it were thought appropriate to extend …
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
F240 — Hygiene
Recommendation: All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.
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
F7 — Clarity of values and principles
Recommendation: All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment.
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
F8 — Clarity of values and principles
Recommendation: Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers are …
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
F9 — Fundamental standards of behaviour
Recommendation: The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.
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
27 — Professional duty to report concerns
Recommendation: Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do so. Failure to report concerns should be regarded as a …
Gov response: 53. We accept this recommendation. A review of professional codes is under way. 54. Dr Kirkup found that many staff did not raise any concerns about standards of care in the maternity units across Morecambe …
Accepted
WATE-(20) — Expedite disciplinary proceedings for child abuse, independent of police investigations
Recommendation: Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any …
Unknown
WATE-(21) — Remind personnel of suspension guidelines: child's best interests, neutral, avoid long periods
Recommendation: Personnel departments and other persons responsible for disciplinary proceedings within local authorities should be reminded that: (a) in deciding whether or not a member of staff should be suspended following an allegation of abuse to a looked after child, first …
Unknown
WATE-(60) — Clearly define purpose and scope of visits to children's homes
Recommendation: The purpose and scope of visits to children's homes, whether by councillors or by senior and intermediate managers, should be clearly defined and made known to all such visitors.
Unknown
WATE-(61) — Make willingness to visit children's homes pre-condition for committee appointment
Recommendation: The willingness of councillors to visit children's homes should be a pre-condition of appointment to the committee responsible for the homes and the importance of fulfilling the duty to visit and to report on visits conscientiously should be emphasised to …
Unknown
WATE-(9) — Make failure to report child abuse by staff an explicit disciplinary offence.
Recommendation: Consideration should be given to requiring failure by a member of staff to report actual or suspected physical or sexual abuse of a child by another member of staff or other person having contact with the child to be made …
Unknown
POH-11 — Apply best offer principle equally in GLOS
Recommendation: The "best offer" principle which will apply in HSSA, as explained in response to Recommendation 10, shall be equally applicable in GLOS.
Gov response: Department for Business and Trade accepts this recommendation. The "best offer" principle applies equally across GLO, HSSA, and HCRS schemes at all panel stages. This has been in effect since 12 August. DBT will retrospectively …
Accepted
Delivered
RHI-40 — Declaration of Interests
Recommendation: Ministers, Special Advisers and officials in Northern Ireland government Departments should declare their interests annually in writing. When any conflict of interest arises during the course of government business each individual should understand that he/she has an obligation formally to …
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
Delivered
ICL-7 — Legal Responsibility Awareness
Recommendation: Awareness of legal responsibilities should be raised among LPG suppliers and consumers.
Gov response: We accept Lord Gill's recommendation that HSE should, in consultation with UKLPG, prepare practical advice for LPG users regarding the fulfilment of their statutory duties. Improved access to practical advice can contribute significantly to improving …
Accepted
Delivered
R32 — Staffing concerns escalation
Recommendation: Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.
Gov response: Section 4.1 of the Scottish Government's response highlights that the NMC code requires registered nurses and midwives to escalate concerns regarding patient safety or the level of care. To support this, a national whistleblowing policy, …
Accepted
R45 — Manager IPC job description
Recommendation: Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job description.
Gov response: Section 2.2 of the Scottish Government's response details the specific responsibilities of the Infection Control Manager (ICM), including overall responsibility for coordinating prevention and control of infection throughout the NHS board area and delivering the …
Accepted
R46 — ICM direct responsibility
Recommendation: Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.
Gov response: Section 2.2 of the Scottish Government's response clearly states that the Infection Control Manager (ICM) has overall responsibility for coordinating prevention and control of infection throughout the NHS board area and delivering the board-approved infection …
Accepted
R51 — ICT functions as team
Recommendation: Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.
Gov response: Section 2.1 of the Scottish Government's response highlights the role of the national HAI Taskforce, which coordinates, implements, and monitors actions across NHS Scotland to reduce HAIs, working with local teams and existing structures. The …
Accepted
R56 — Regular IPC group meetings
Recommendation: Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.
Gov response: Section 2.2 of the Scottish Government's response notes the recommendation that NHS boards should ensure infection prevention and control is explicitly considered at all clinical governance committee meetings. Section 2.1 describes the national HAI Taskforce, …
Accepted
R57 — IPC committee minutes reporting
Recommendation: Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy.
Gov response: Section 4.2 of the Scottish Government's response details that registered health professionals must meet professional standards on record-keeping established by their regulatory bodies, and the Scottish Government has its own Records Management: NHS code of …
Accepted
PFD Reports (68)
Clive Hyman
Concerns: Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.
Overdue
Dhananji Dona
Concerns: The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.
Overdue
Wayne Walton
Concerns: Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential conflicts of interest when staff recognise patients outside of personal relationships.
Response: The Trust has updated and re-launched its policy guidance on risk assessments, risk management, and safety planning for patient discharge, with associated staff training for inpatient teams. Additionally, new guidance …
Responded
Anthony Binfield
Concerns: A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.
Responded
Samuel Stewart
Concerns: No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.
Response: Practice Plus Group clarifies that healthcare was not informed of the positive drug test, which prevented them from taking action. They then detail their existing process for managing positive drug …
Response: HM Prison and Probation Service confirms that following a positive drug test on an ISFL wing, prison staff are required to refer the prisoner to the Forward Trust, who then …
Overdue
Maureen Christy
Concerns: There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Response: Blackpool Teaching Hospitals plans to roll out a digital solution called ‘Alertive’ from Q4 2025/2026 to improve the dissemination of critical messages and ensure staff acknowledgment of policies, with scoping …
Responded
Sonia Sore
Concerns: The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.
Responded
Hazel Gambles
Concerns: There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.
Responded
Valerie Hill
Concerns: The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.
Responded
Paul Reeves
Concerns: Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating resident to the mental health team, hindering proper assessment.
Responded
Peter Jones
Concerns: Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and monitoring failures.
Responded
Vauna Leeming
Concerns: Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Responded
Edith Pye
Concerns: The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in ensuring resident safety.
Responded
Paul Gobell
Concerns: There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.
Responded
Gloria Linton
Concerns: Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and injury.
Responded
Raymond Reid
Concerns: Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.
Responded
Kashim Ali
Concerns: Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Responded
Susan Edwards
Concerns: A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.
Responded
Clara Winter
Concerns: Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving a significant learning gap.
Responded
Jada Monoja
Concerns: An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Responded
Samantha Angel
Concerns: Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. The system failed to accelerate the process despite the evident harm.
Responded
Donna Smith
Concerns: A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.
Responded
Sean O’Connor
Concerns: The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of harm.
Responded
Neville Abbott
Concerns: A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management opportunities.
Responded
Ash Bannister
Concerns: Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.
Responded
Cariss Stone
Concerns: Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.
Responded
Giuseppe Tabone and Andrew Evans
Concerns: Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
Responded
Daniel Tucker
Concerns: Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.
Responded
Gillian Baumgardt
Concerns: There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury site between x-ray images, risking wrong-site surgery.
Responded
June Peel
Concerns: Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate care without timely medical attention.
Responded
Doris Smith
Concerns: Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
Responded
Liridon Saliuka
Concerns: There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Responded
Khalid Abiaz
Concerns: A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Responded
William Savory
Concerns: There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.
Overdue
Jake Cahill
Concerns: Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Responded
Mark Castley
Concerns: The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.
Responded
Kyle Nel
Concerns: The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.
Responded
Robert Hammond
Concerns: The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.
Responded
Cpl Ryan Lovatt
Concerns: The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Responded
Henry Holcombe
Concerns: The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Responded
Valmai West
Concerns: Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Responded
Shirley Froggett
Concerns: New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Overdue
Michael Dent-Jones
Concerns: National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.
Responded
Theresa Robertson
Concerns: The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Overdue
Mary Chapman
Concerns: The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.
Responded
Ricky Barcock
Concerns: The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially drug users, to properly monitor their wellbeing.
Overdue
Agnes Lambert
Concerns: Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Responded
Austin Thomas
Concerns: Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random testing despite evidence of an employee's drug use.
Overdue
Rosalind Flett
Concerns: Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially missing concealed items.
Overdue
Dominic White
Concerns: A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition regarding the absconding risk when allowing a detained patient leave.
Overdue
Charlotte Agnew
Concerns: Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without direct psychiatrist assessment, compounded by significant re-assessment delays.
Overdue
John Williams
Concerns: Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.
Overdue
Wayne Cornlouer
Concerns: An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Responded
Warren Sampson
Concerns: Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Overdue
Maureen Flynn
Concerns: A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Responded
Lee Gaunt
Concerns: The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's death, indicating a general lack of support for staff in stressful situations.
Responded
Douglas Birch
Concerns: Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did not consistently receive or read crucial Prison Service Orders.
Responded
Arthur Fry
Concerns: A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Responded
Gail Prentice
Concerns: There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.
Overdue
Bruce Longden
Concerns: The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
Responded
Mark Groombridge
Concerns: Critical lack of communication between offender managers and hospital clinicians before recall, alongside widespread confusion among probation staff about the recall process, created systemic failures.
Responded
Austen Harrison
Concerns: Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an unsafe mirror.
Responded
John Lowe
Concerns: Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
Overdue
Seweryn Glowinski
Concerns: Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Overdue
Rajesh Parkash
Concerns: Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Overdue
Doris Taylor
Concerns: Staff training was inadequate regarding reportable incidents, and managers were unaware of reporting duties. Dangerously strong door-closers also posed a significant safety hazard to residents.
Overdue
Kevin Pearson
Concerns: The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized activities.
Overdue
Ryan Chapman
Concerns: Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
Overdue