Staff rota communication
Failures in communicating staff rota changes directly to staff members, relying solely on electronic system updates.
182 items
14 sources
3 inquiries
Source spread
Where this theme appears
Staff rota communication has been flagged across 14 independent accountability sources:
4 inquiry recs
94 PFD reports
1 committee rec
12 CQC actions
2 HMICFRS recs
2 ICIBI recs
2 PPO recs
9 IOPC recs
3 IMB reports
43 IMB recs
1 Article 2 learning point
3 detention investigation recs
5 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 (4)
LADB-46 — Establish and apply criteria for signallers exceeding maximum 72-hour work week
Recommendation: Railtrack management should set out the criteria for allowing signallers, in exceptional circumstances, to exceed the maximum of 72 hours of work per week, and ensure that these criteria are, and continue to be, correctly applied (para 12.19).
Unknown
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Gov response: Section 4.1 of the Scottish Government's response discusses general workforce planning, including the use of nursing and midwifery workload and workforce planning tools to determine the number of nurses or midwives needed. However, the provided …
Accepted
IHRD-18 — On-Call Consultant Display
Recommendation: The names of all on-call consultants should be prominently displayed in children's wards.
Gov response: On-call consultant information displayed in children's wards.
Accepted
LADB-12 — Increase driver briefing frequency with safety as primary agenda item
Recommendation: Thames Trains should increase the frequency of the briefing of drivers with a view to ensuring that each driver has a face to face meeting with his or her driver standards manager at least monthly, if not more often, and …
Unknown
PFD Reports (94) — showing 50 strongest matches
Nicola Matthews
Concerns: Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
Overdue
Susan Jill Hammond
Concerns: Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.
Response (United Lincolnshire Hospitals NHS): United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between …
Responded
Sean Seabourne
Concerns: Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.
Overdue
Christopher James Morgan
Concerns: The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Overdue
Joanne Manning
Concerns: A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency information-sharing policy.
Overdue
Barbara White
Concerns: Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
Overdue
Brian Belfield
Concerns: Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race control and marshals, leading to a missing runner.
Overdue
Margaret Walker
Concerns: Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Response (5 Boroughs Partnership NHS Foundation Trust): The Trust has reviewed its medicines policy, will issue further guidance on medicines reconciliation, has implemented Trust-wide initiatives for managing physical health and diabetes, developed diabetes guidelines, introduced Diabetes Link …
Responded
Winifred Dennis
Concerns: Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.
Response (Kent Community Health NHS Trust): Kent Community Health NHS Trust has devised a formal process for transfer of care between community nursing teams. A working group has been established to revise policies and procedures, improve …
Responded
Ryan Boyle
Concerns: Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.
Response (Surrey Police): Surrey Police updated its pursuit management guidance to align with ACPO guidance, installed a 'Call Supervisor' button in the Force Control Room, and briefed staff that two people must monitor …
Responded
Dayani Chauhan-Ahmed
Concerns: Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
Response (University Hospital of Leicester NHS Trust): The trust plans to implement several changes, including a proforma for communications during labour, reinforcement of the escalation policy, consultant presence at the LRI, and an annual emergency drill to …
Responded
Antonio Allen
Concerns: Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.
Response (Central Manchester University Hospitals NHS): Following a telephone line failure, women are now given two telephone numbers to call for planned home births. A standard operating procedure is in place to check essential telephone lines …
Responded
Awa Jeng
Concerns: A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Response (Barts Health NHS Trust): The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of …
Responded
Daniel Strickland
Concerns: Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.
Overdue
Archie Hexall
Concerns: A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.
Response (Lewisham Greenwich NHS Trust): Lewisham Greenwich NHS Trust has implemented actions, including a 'learning from incidents' policy requiring staff to document and handover clear information and a review of handover documentation. They have also …
Responded
Tamara Holboll
Concerns: The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.
Response (Camden and Islington NHS Trust): Camden and Islington NHS Trust has amended the action plan template and revised guidance for writing recommendations, adding an action row to prompt authors to write an action for each …
Responded
Brian Gillard
Concerns: A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.
Overdue
Michael Hanlon
Concerns: An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Response (Pluteus Limited): A keyless entry system has been installed to address concerns around access, and a 24-hour watch system is in place when owners/guests are onboard. A Captain's Standing Order is to …
Responded
Harry Pryal
Concerns: A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.
Response (Department of Health): The response acknowledges concerns, noting that local providers are best placed to address system issues. It highlights the move to digital care records and the development of standards for clinical …
Response (Wigan Borough CCG): The CCG has requested that SBP have a service agreement in place with a provider for physiotherapy and occupational therapy; SBP has confirmed that all requests for these therapies will …
Response (5 Borough Partnership NHS Trust): The Trust has developed a standardised proforma for transfer between Trusts, shared with colleagues in Wrightington, Wigan and Leigh NHS Foundation Trust and discussed at the Wigan Medical Staff Committee. …
Response (Wrightington Wigan and Leigh NHS Trust): The Trust has developed a proforma for telephone advice, has updated the radiology information system and implemented 'hot reporting' during weekdays. Specialist Radiographer chest X-ray reporting has been introduced.
Responded
Alan Tear
Concerns: Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was unclear.
Response (University Hospitals of Leicester NHS Trust): The matron met with all nursing staff on the ward to discuss what had occurred in this case, emphasizing awareness of required observation frequency. The Interim Deputy Medical Director and …
Responded
Matthew Crowley
Concerns: A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
Overdue
Freda Weston
Concerns: Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Response (Weston): Stockport NHS Foundation Trust will supply Patient Information Leaflets with monitored dosage systems, including a generic medicine patient information leaflet. All wards in the Medicine Business Group have access to …
Responded
Martha Davies
Concerns: Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and poor documentation.
Overdue
Michaela Thompson
Concerns: Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
Response (Leeds and York NHS Trust): The trust acknowledges the need for clear documentation of MDT meetings and recording phone calls. They propose a meeting to discuss the practicalities of recording calls before implementing a solution.
Responded
Winifred Elliott
Concerns: The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.
Response (CQC): The CQC outlines its inspection process regarding moving and handling, stating it assesses providers' performance against regulations but cannot compel specific systems; it will take action against providers failing to …
Overdue
David Cooper
Concerns: Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.
Response: The University Health Board established a Falls Management Group, reviewed policies and training requirements, introduced National Patient Safety Agency's Risk Assessments, devolved falls management to Directly Managed Units, and will …
Overdue
Lita Serkes
Concerns: Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.
Response (Barts Health NHS Trust): Barts Health NHS Trust has briefed medical staff on complete record-keeping, reiterated the availability of point-of-care tests, and is giving ongoing training to nursing staff in the use of PCA …
Responded
Jane Stables
Concerns: Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.
Response (Allied Healthcare): Allied Healthcare acknowledges the concerns and will perform a review of practices/policies/procedures relating to the use of slide sheets and update the Senior Coroner. They confirm that all of Allied …
Response (RDASH): RDASH held a meeting with District Nurses and their Line Managers to discuss the report. Training on pain management in patients with dementia and cognitive impairment is ongoing and will …
Responded
John Atkinson
Concerns: The coroner identified a lack of updated risk assessments, failure to identify changes in presentation and risk level, absence of a system for managing patients of departing staff, and ineffective communication among mental health professionals and with the patient and family.
Response (Rotherham Doncaster and South Humber NHS Trust): The trust intends to address the need for increased capacity to conduct basic out-of-hours patient reviews and is considering options to expand out-of-hours community provision as part of its service …
Responded
David Moran
Concerns: The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical staff also appeared ineffective.
Response (5 Borough Partnership NHS trust): The Trust has implemented a telephone system for the Assessment Team, piloted in Warrington in December 2016 and due Trust-wide by April 2017. All information relating to patients and their …
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
Robert Cardwell
Concerns: Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Overdue
Rayan Ahmed
Concerns: Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.
Overdue
Mohammad Ashraf
Concerns: Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.
Response (Birmingham Community Healthcare): The Trust confirms that it has worked with Al-Hijrah school to provide a full response, and that its comments have been incorporated into the school's letter.
Response (Al Hijrah School): This response is not classifiable as it appears to be a scan of a coversheet only. The content is unreadable and does not contain any meaningful information about actions taken …
Responded
Philip Powell
Concerns: Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
Response (Dudley Group NHS Trust): The Trust has equipped all District nurse bags with a box of Debrisoft and has held a meeting with the Debrisoft Rep to discuss the issues when raising a prescription …
Responded
Doreen Wilkins
Concerns: Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.
Response (Comfort Call): Tameside Borough Council agreed to pay an additional sum for travel time between care assignments, allowing Comfort Call to include travel time as a separate element in staff rotas. This …
Responded
Catherine Kennedy
Concerns: Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.
Response (Pennine Care NHS Trust): The Situation, Background, Assessment, Recommendation (Decision) tool is currently taught within several courses and the Organisation Learning and Development have been supplying learners with a copy of the A5 SBAR(D) …
Response (Greater Manchester Mental Health NHS Foundation Trust): The organisation has developed an action plan relating to the points raised during the inquest, which includes the re-design of Community Mental Health Services and an apology to Ms Kennedy's …
Responded
Derek Smith
Concerns: Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
Overdue
Bradley Morgan
Concerns: Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.
Response (NHS England): NHS England will ensure services are commissioned and provided to ensure risk assessments are available 24/7, and the CCG will meet with the local authority to address differences in opinion …
Response (NHS Birmingham and Solihull ICB): The CCG provided funding to Forward Thinking Birmingham (FTB) for a personality disorder pathway and clinical lead, and invested in BSMHFT to appoint a clinical lead for personality disorder; they …
Responded
Mary Johnson
Concerns: Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
Response (Wye Valley NHS Trust): • The use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld, has been relaunched and clarified to all pertinent staff. • All speciality specific …
Responded
Gail Bailey
Concerns: A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.
Overdue
Calary Davis
Concerns: Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.
Response: A corrective Action Plan for Improvement was developed following Calary Davis' death and has been updated to reflect the concerns identified within the Regulation 28 Report. Staffing has significantly improved …
Responded
Tamsin Grundy
Concerns: A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental health. Despite being noted, no definitive action was taken to address this issue.
Response (Norfolk Suffolk NHS Trust): The CRHT team is using a national fidelity scale, including a point on therapeutic relationships, to reflect on practices and identify areas for improvement, matching clinicians with individuals where a …
Responded
Muhammed Haleem
Concerns: The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.
Response (North West Ambulance Service NHS Trust): NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be …
Response (Pennine Care NHS Trust): Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs …
Responded
Mary Jones
Concerns: Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.
Overdue
Amy Allan
Concerns: Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Response (Great Ormond Street Hospital for Children): Great Ormond Street Hospital has improved the spinal surgery pathway with intensive care and ECMO support, including ensuring relevant MDT members are involved in decisions, creating consultant-level handovers to ICU, …
Responded
David Potts
Concerns: Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.
Overdue
Karis Braithwaite
Concerns: Important risk information provided by a paramedic was not available to the MHA assessment team, and insufficient steps have been taken to improve the handover process from first responders to Trust staff following serious incidents in the community.
Overdue
Rebecca Hursey
Concerns: Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.
Overdue
Sarah Young
Concerns: A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.
Overdue
CQC Inspection Actions (12)
Holly House Residential Care Home
The provider must ensure that staffing rotas accurately demonstrate staffing numbers, reflect all shifts worked, and reconcile with payroll records and actual hours worked.
Must Do
Affinity Trust Specialist Support Division North
People's needs and any changes in their care and support was not always shared with staff.
Must Do
TerraBlu Homecare
Other people and relatives did not have the same experiences. One person told us, "I asked for a 08.00am call and at first I was getting calls at 07.00 am or 07.30 am, it's better now but they never call …
Should Do
Shining Star Home Care Limited
Improvements were required for staff's schedules, so the provider could be assured staff were attending calls in line with the person's time preference.
Should Do
Prospects for People with Learning Disabilities - 3 Norwich Road
Staff meetings were not as regular as they would like them to be. It was difficult to arrange a time when most of the staff would be able to attend. There was still a poor turn out at the meetings …
Should Do
London Hair Transplant Clinic
The service should ensure that staff meetings are well attended and the minutes contains sufficient detail to provide a clear understanding of what was discussed.
Should Do
Care Outlook (Bellerophon House)
The regional manager added this to the action plan for the service to ensure any changes to staff rotas are made through direct communication with the staff member rather than changes to the rota in the electronic system used by …
Should Do
Bromsgrove
The service should ensure staff meeting minutes have sufficient detail for staff who do not attend the meeting to understand what is discussed.(Regulation18).
Should Do
Verve Health
The service should ensure that regular full staff meetings, staff multi-disciplinary meetings and handovers occur in order to discuss service user needs, share relevant key information and share learning or areas for improvement.
Should Do
Monaveen
The provider must ensure governance systems sustain improvements and address failures in communication and engagement with people and staff.
Must Do
St Clare's Hospice
The provider should review the on call arrangements for the hospice and ensure there is clarity in regard to which managers are on call.
Should Do
Age Concern Home Care Central Manchester
We recommend that the registered manager has improved oversight of the electronic call monitoring system and processes to ensure people receive care at the right time.
Should Do
HMICFRS Recommendations (2)
FRS 2021-22 CoC Recommendations: Northumberland Fire and Rescue Service
Cause of concern: The management of dual contracts, for staff working on-call and wholetime in the service, must be improved. Recommendation: By 31 March 2022, the service should:- review its current arrangements for managing the working time of staff who …
Recommendation
FRS 2021-22 CoC Recommendations: Northumberland Fire and Rescue Service
Cause of concern: The management of dual contracts, for staff working on-call and wholetime in the service, must be improved. Recommendation: By 31 March 2022, the service should:- make sure staff take appropriate breaks between on-call and wholetime commitments for …
Recommendation
ICIBI Immigration Recommendations (2)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and …
An inspection of Border Force operations at Stansted Airport
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and …
PPO Death in Custody Recommendations (2)
The Head of Healthcare
The Head of Healthcare should review the process of sharing information between one shift and the next.
The Governor of Stafford
The Governor of Stafford should ensure that officers taking over bedwatch duties read the bedwatch log at the start of their shift, so they are aware of any ongoing issues.
IOPC Learning Recommendations (9)
Recommendations - Sussex Police, November 2019
There was a lengthy delay in resourcing a request for a welfare check that was graded Grade 2 (expected response time 1 hour). There were resourcing issues that led to this delay, the incident log provided very little information about …
Recommendations - Sussex Police, November 2019
There was a lengthy delay in resourcing a request for a welfare check that was graded Grade 2 (expected response time 1 hour). There were resourcing issues that led to this delay, the incident log provided very little information about …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police implement a policy to ensure that there is consistency in how LPU sergeants inform the control room staff about availability of their staff to be deployed. Some sergeants provide the control room with a …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police clarify and/or implement/formalise an escalation process when there are outstanding matters to be resourced. Due to the lack of policy, some staff members inform their supervisors whilst other do not. This incident was left …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police implement a policy to ensure a clean handover from one LPU shift to the next takes place. No handovers were recorded at shift change times. The IOPC is aware that Derbyshire have implemented some …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police introduce a policy and guidance for the management of the different lists of jobs, so supervisors are aware of their responsibilities in relation to them. The supervisors within the LPU were not aware of …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police standardise terminology within the local policing unit (LPU) and the control room for the lists of jobs to be managed and dealt with to avoid any confusion as to who is responsible for what. …
Recommendations - Metropolitan Police Service, June 2024
The IOPC recommends that the MPS should increase awareness amongst officers regarding the Resource Management Policy, particularly concerning the booking on and off of colleagues other than themselves through the CARMS system. Training should be put in place to ensure …
Recommendation - Metropolitan Police Service, October 2024
The IOPC recommends that the Metropolitan Police Service (MPS) should put a process in place to re-allocate workloads where there is confirmation of an investigator’s absence from their role for a period of time either on leave, secondment or for …
IMB Annual Reports (3)
Ford (2021)
HMP Ford experienced a challenging year marked by Covid-19 restrictions, which the prison successfully managed, limiting outbreaks and reducing violence. Significant accommodation changes occurred with the condemnation of B wing and the introduction of new pods, which, despite initial issues, led to a reduced but more modern estate. The Board commended the prison's efforts in restoring and increasing external employment opportunities for prisoners post-restrictions, contributing positively to resettlement goals.
PRISON
Key concerns
Buckley Hall (2025)
HMP Buckley Hall, a Category C training prison, has a population of 460 men. The Board noted significant improvements in healthcare and positive engagement in DARS and family visits, alongside strong staff dedication. However, chronic staff shortages severely impact the regime, leading to frequent lockdowns and cancelled activities. Key concerns include an ineffective maintenance contract, persistent property issues during transfers, and the detrimental impact of the birthday parcel policy. The Board also highlighted tired accommodation, hygiene issues, and a high number of self-harm incidents.
PRISON
Key concerns
Bronzefield (2025)
HMP/YOI Bronzefield, a women's local and YOI prison, reported a population of 506 and a CNA of 5271. While some progress was noted in leadership and property management, the report highlights significant concerns regarding healthcare delivery, staffing pressures, and the impact of roll-counts on the regime. Mental health services remain strained, and issues with food provision, complaint handling, and resettlement support persist, many of which were repeated from previous years.
PRISON
Key concerns
IMB Recommendations (43)
Coldingley (2023)
Changes which affect prisoners have not always been well communicated within Coldingley. This creates an atmosphere of confusion and at times hostility. What can the Governor do to improve the methods of communication to ensure all prisoners understand the changes and why they are considered necessary?
Governor / Director
Wealstun (2020)
Ensure that post is collected from the post room daily by the wing staff (see paragraph 7.2.4).
Governor / Director
Ford (2021)
Communication has continued to be a problem. During lockdown you held regular forums attended by a representative from each corridor but the information given out did not seem to reach the other prisoners in spite of the fact that the forums were each followed up by a notice to the community. Prisoners also reported that communication with staff, particularly the …
Governor / Director
Altcourse (2022)
Recruitment of staff has to be a priority to minimise the redeployment of staff from designated roles to cover for vacancies elsewhere.
Governor / Director
Ranby (2023)
More staff interaction, better information for prisoners to know who their offender manager and personal offender manager are.
Governor / Director
Huntercombe (2023)
How will the Governor work with staff to ensure that the roll call is accurate, so that prisoners are not disadvantaged by not being able to attend work, education or healthcare?
Governor / Director
Fosse Way (2025)
Communications could, in our view, be better with various committees/meetings cancelled or changed at short notice without the IMB being informed. This has resulted in situations where we have arrived at a meeting and it has not taken place.
Governor / Director
Berwyn (2022)
The Board is concerned that the establishment is regularly impacted by staffing shortages, causing restricted regimes and impacting upon important initiatives such as key work.
HMPPS
Oakwood (2021)
The Director to review the range of alternative communication options in addition to communication via the kiosks on the wings. Prisoners have commented that, at times, they were not always aware of the arrangements for Purple Visits and exercise times, which appears to be linked to the lack of time available to the prisoners to use the kiosk during lockdown. …
Governor / Director
Lancaster Farms (2021)
To review the suitability and implications of making transfers between prisons on Fridays (4.1.2).
HMPPS
Wymott (2022)
On a number of occasions, poor communication between functional areas has led to conflicting information being provided to both prisoners and Board members. What strategies does the Governor have to improve this?
Governor / Director
Standford Hill (2022)
It appears to the Board that communications between GFSL and the prison needs to improve radically in order to ensure that those parts of the prison dependent on the work of GFSL are enabled to run smoothly.
HMPPS
Send (2023)
The Board is concerned about the impact of prison staffing issues on delivering regular keywork as intended in the OMiC model.
Governor / Director
Kirkham (2023)
The IMB recommends that there should be a strategy for when activities are curtailed, due to redeployment of staff, to deal with absences/emergencies.
Governor / Director
Five Wells (2023)
The Board’s rota reports have highlighted that inconsistencies and frequent changes in regime have undermined the running of the houseblocks, with some staff feeling unsupported and lacking the confidence to enforce where necessary. What action will be taken to remedy this?
Governor / Director
Feltham (2023)
Please could more information be made available regarding TOoR - e.g. inclusion of data in Daily Briefing and flagging all children with less than two hours TOoR?
Governor / Director
Deerbolt (2023)
The Board believes that HMPPS needs to improve the property-handling process and access to the facilities’ list, which sets out when clothing parcels can be applied for and the process for an application.
HMPPS
Deerbolt (2023)
The Board recommends that the prison makes these documents [incentives scheme and facilities list] readily available on each wing.
Governor / Director
Swaleside (2024)
With the staffing ratio now up, due in part to the temporary closure of two wings, the Board now expects the low level of keywork to be addressed.
Governor / Director
Sudbury (2024)
The Board has continued to note that some prisoners perceive there to be inconsistencies between the OMU staff, in terms of processing ROTL applications, but also acknowledges the recent changes to the systems in use and the appointment of additional management in the area. An ongoing concern raised by prisoners is the lack of regular communication between them and the …
Governor / Director
Styal (2024)
What progress is being made in reducing non-attendance at healthcare, education and activities, caused by scheduling conflicts.
Governor / Director
Risley (2024)
Staff absences over summer months continue to hinder the regime, particularly in access to workshops. Does the organisation plan to evaluate its staffing provision at peak times of leave throughout the year?
HMPPS
High Down (2024)
The Governor should improve communication with prisoners, particularly with regards to regime changes.
Governor / Director
Bullingdon (2024)
What steps will the Governor take to address the significant decrease in key working?
Governor / Director
Bronzefield (2024)
What plans does Sodexo have to address the significant impact of staff shortages on the provision of services in the prison? (3.1, 5.3)
Other
Bronzefield (2024)
Roll count has frequently been late, which has had a negative impact on the regime and security. How will the prison ensure that roll count returns to being accurate and timely? (4.6)
Governor / Director
Thameside (2025)
The Prison Service, in conjunction with the Prisoner Escort and Custody Service, should take actions to minimise court vans regularly arriving at the prison after the 8:00 pm lock-out time.
HMPPS
Morton Hall (2022)
tightening up and/or amending the processes for roll reconciliation so that prisoners can take part in planned activities on time (see paragraph 6.5.4).
Governor / Director
Channings Wood (2022)
What can be done to ensure that men arriving at Channings Wood late on a Friday receive the same level of support during the reception process as those arriving during the working week?
Governor / Director
Channings Wood (2022)
Prisoners arriving late on a Friday report a significantly poorer induction experience than those arriving during the core working week. What will the Prison Service do to minimise the number of routine planned transfers taking place on a Friday?
HMPPS
Feltham (2023)
Could someone identify which spaces are available for outreach meetings. e.g. out-of-use corner rooms, etc?
Governor / Director
Drake Hall (2023)
The Board would like access to PSIs to be improved for women in the open unit and the CSU.
Governor / Director
Bure (2024)
The Board remains concerned that education and workshop classes are underused, due to conflicting healthcare appointments and activities.
Governor / Director
Buckley Hall (2024)
Concerns have been raised about the restrictive timing of the social video calls, which impact on a family’s ability to utilise them.
Governor / Director
Bronzefield (2024)
What plans does the prison have to prioritise prisoner/key worker meetings for those prisoners who have been identified as most likely to benefit from them? (5.3)
Governor / Director
Swaleside (2025)
Staff and prisoner relationships have been damaged by the huge influx of inexperienced staff. Will the Governor reassure the Board that the recent recovery in key work sessions from a low base will be matched with quality assurance?
Governor / Director
Styal (2025)
What plans are in place to allow the current limited supervision of the houses to be extended, to enable staff to respond to prisoner requests and listen to their concerns?
Governor / Director
Ashfield (2025)
The impact of key work reporting, providing escort staff in hospital and occasional redeployment to other Serco prisons has meant fewer wing officers available, all of which has resulted in low staff morale. What steps are being taken to relieve these pressures?
Governor / Director
Wetherby (2021)
The lack of permanence within the senior management team is of great concern to the Board. Is the Governor able to offer reassurance to the Board that some level of stability will take place? Barnardo’s advocacy has an important role to play in supporting the young people. They hear of Barnardo’s role, along with that of many others, during the …
Governor / Director
Cookham Wood (2023)
What urgent steps will Cookham Wood take to ensure a stable and predictable regime for the boys, with improved time out of cell and minimal last-minute changes and cancellations?
Governor / Director
Isis (2024)
What alternative methods are there for bringing urgent but not emergency issues to the attention of officers?
Governor / Director
Whitemoor (2025)
Will the Governor take action to prevent interruptions to key functions such as visits management due to lack of resilience in staffing?
Governor / Director
Bure (2025)
Why are prison officers sent on ‘detached duties’ (deployed at prisons away from their usual base) when it leaves Bure with staff shortages, especially when most days several staff are required to be out of the prison for planned and unplanned escorts to hospital? Staff shortages in the establishment are impacted further by bed watches.
HMPPS
Detention Investigations (3)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 8
Group 4 reviews its roll count procedures to ensure they are accurate and efficiently carried out.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 38
I recommend that IND and its contractors jointly review the shift patterns worked by staff in the immigration detention arena.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 48
GSL reviews its shift systems with a view to ensuring consistency of operation and that staff are able to perform at their optimum throughout their duty.
Immigration Detention
LGO / SPSO Decisions (5)
24-012-733 — Leicester City Council
Summary: The Council was at fault for its handling of Mrs X’s school transport application and subsequent appeal. It gave Mrs X inaccurate information, and its appeal response lacked the detail required by the statutory guidance. This caused Mrs X significant distress, uncertainty, time and trouble. The Council has agreed …
LGO (Local Government & …
Education
Upheld
Jun 2025
201600725 — Lothian NHS Board - Acute Division
Miss C complained about the care and treatment she received at St John's Hospital. She had been diagnosed with skin cancer and had an operation in the hospital to remove the cancer. She said that, after the operation, the anaesthetist refused to give her further pain relief without having seen …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2017
22-004-483 — Wokingham Borough Council
Summary: We will not investigate this complaint about the Council changing the hours of operation of one of its offices. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Jul 2022
22-004-845 — Coventry City Council
Summary: We will not investigate this complaint about the Council carrying out non-essential work outside the complainant’s house on the day of their late mother’s funeral. There is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Transport And Highways
Aug 2022
22-006-242 — Spelthorne Borough Council
Summary: We will not investigate Miss X’s complaint about the Council’s decision to change where she should store her waste bins. We cannot make findings on the land ownership and legal issues at the core of the complaint so cannot achieve a different outcome from investigating or get her the …
LGO (Local Government & …
Environment And Regulation
Aug 2022