Unclear healthcare delegation
Weak and unclear guidance on the delegation of healthcare responsibilities within schools, leading to insufficient clarity.
51 items
8 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
100match
#82 - Guidance on delegating healthcare responsibilities within schools remains weak and unclear.
Guidance on the delegation of healthcare responsibilities within schools and multi-academy trusts remains weak. There is insufficient clarity on how and when healthcare tasks can be appropriately and safely assigned to school or multi-academy trust staff, what training and safeguards should accompany such delegation, and ultimately where responsibility lies between education and health services. This lack of direction...
Matched on
terms: delegation, healthcare, unclear
Committee recommendation
95match
#83 - Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with school and multi-academy trust leaders and health and education unions and set out clear lines of accountability between...
Matched on
terms: delegation, healthcare
PFD report
61match
Violet Cloudsdale
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
Matched on
terms: unclear
PFD report
61match
Alison Dallow
Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. There was also no documented evidence of information provided to the patient.
Matched on
terms: unclear
PFD report
61match
Catriona Martin
There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.
Matched on
terms: delegation
PFD report
61match
Rachel Gibson
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Matched on
terms: unclear
PFD report
57match
Eleanor Brabant
Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood their powers to detain informal patients. Confusion also existed regarding family involvement in care planning.
Matched on
terms: unclear
PFD report
57match
Paul Reeves
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.
Matched on
terms: unclear
PFD report
53match
Marjorie Nesbitt
Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.
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classifier match
PFD report
53match
Harold Wilberforce
A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted help. There's a critical lack of clarity regarding staff responsibilities in such situations.
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classifier match
PFD report
53match
Hannah Jacobs
Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, and parents on the importance of carrying adrenaline auto-injectors.
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classifier match
PFD report
49match
Samantha Gould
There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
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classifier match
PFD report
49match
David Bennett
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, medication reviews, and proper risk assessment.
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classifier match
PFD report
49match
Pamela Marking
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their competency.
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classifier match
PFD report
49match
Hailey Thompson
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record of the handling.
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classifier match
CQC action
48match
We Can Recover CIC
Although the service had contracted a named GP prescriber, their role and cover arrangements remained unclear. The registered manager could not confirm if the named doctor was acting as an independent doctor or prescribing care and treatment under the regulated activity accommodation for persons who require treatment for substance misuse on behalf of or employed by, We Can...
Matched on
terms: unclear
PFD report
45match
Alexander Davidson
NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
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classifier match
PFD report
45match
Stanley Babbs
Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.
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classifier match
PFD report
45match
Amarbai Bhudia
Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a failure to properly escalate concerns about its function were identified.
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classifier match
PFD report
45match
Christian Tuvi
A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, resulted in an unsafe system relying on temporary measures.
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classifier match
PFD report
45match
Katherine Flynn
A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops draining but oscillates poses a significant patient safety risk.
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classifier match
PFD report
45match
Christopher O’Donnell
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental health crisis.
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classifier match
PHSO casework decision
44match
P-004450 - Royal Devon University Healthcare NHS Foundation Trust
Mr B complains the Trust inappropriately changed a planned anaesthetic when it attempted to insert a suprapubic catheter in December 2023.
Matched on
terms: healthcare
Committee recommendation
40match
#1 - Absence of a departmental definition for inclusive education hinders clarity and investment planning.
We welcome the Department’s focus on inclusive education; however, we are concerned about the absence of a Departmental definition of this and the subsequent lack of clarity about what ‘inclusive mainstream’ education looks like and means in practice for educators, education settings, pupils and families. We are also concerned that the Department does not appear to have a...
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classifier match
Committee recommendation
36match
#2 - Publish a clear definition of inclusive education with rationale and good practice examples.
It is unacceptable that a clear definition of inclusive education is still lacking. The Department must publish a definition of inclusive education and rationale for this vision alongside examples of good practice across different phases of education and settings within the next 3 months. Continued ambiguity undermines progress and accountability. (Recommendation, Paragraph 35)
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classifier match
Committee recommendation
35match
#39 - 12th Report – Menstrual health of girls and young women
We strongly disagree with the Minister’s argument that further ringfenced funding to support NHS Integrated Care Boards to maintain and develop women’s health hubs is unnecessary. The implementation of women’s health hubs is not complete. There are inconsistencies in provision, they do not cover all areas of the country and not all of those that have been established...
Matched on
terms: healthcare
IMB recommendation
35match
Wymott (2024)
The Board has been concerned about the triaging of hospital escorts by Duty Governors, as these are clinical decisions (see section 6.2). Can HMPPS offer assurances that negotiations for the new healthcare contract will address this?
Matched on
terms: healthcare
Committee recommendation
31match
#40 - 12th Report – Menstrual health of girls and young women
We are concerned that women’s health hubs have not been specified in the 2025/6 operational planning guidance. There is a high risk that without a central requirement to deliver women’s health hubs, and with Integrated Care Boards (ICBs) required to find substantial efficiency savings, they will be scaled back or discontinued. We believe this would be a disaster...
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classifier match
PHSO casework decision
30match
P-002366 - NHS England - South (regional office)
Mrs J complains about NHS England's decision that her husband was not eligible for NHS continuing healthcare funding.
Matched on
terms: healthcare
Inquiry recommendation
27match
IHRD-20 - Consultant-Led Ward Rounds
Children's ward rounds should be led by a consultant and occur every morning and evening.
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classifier match
Inquiry recommendation
27match
IHRD-15 - Consultant Notification on Admission
A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior clinical involvement and leadership.
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classifier match
Committee recommendation
27match
#41 - 12th Report – Menstrual health of girls and young women
The renewed Women’s Health Strategy should include a refreshed national commitment to women’s health hubs across England. We recommend the Government invest at least the same amount as in 2023–25 (£25 million) in ringfenced Integrated Care Board funding for women’s health hubs. 77 This should come with increased accountability, including assurance that all hubs meet the core specification....
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classifier match
Inquiry recommendation
23match
IHRD-12 - Senior Paediatric Responsibility
Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.
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classifier match
PHSO casework decision
23match
P-002638 - East Kent Hospitals University NHS Foundation Trust
Miss R complains her father died because the Trust gave him food and drink when he could not swallow after a stroke. She also complains he should have been isolated in a side room to protect him from COVID-19.
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classifier match
LGO / SPSO decision
23match
24-018-678 - City of Bradford Metropolitan District Council
Summary: We have upheld Ms X’s complaint about the Council’s failure to provide adequate information about the costs of adult social care for her father. We asked the Council to remedy the injustice caused. It agreed to apologise and reduce the costs it charges Mr Y. It will also take action to prevent a recurrence of this issue.
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classifier match
LGO / SPSO decision
22match
25-009-869a - Clarity Homecare (Bristol) (25 009 869a)
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Inquiry recommendation
18match
IHRD-21 - Nurse Attendance at Clinical Interactions
The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.
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classifier match
Inquiry recommendation
18match
IHRD-19 - Senior Lead Nurse in Children's Wards
To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating to each patient, be visible to both patients and staff and be available to discuss concerns with parents. Such leadership is necessary to reinforce nursing standards and to...
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classifier match
PFD report
18match
Melanie Pinnell
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline was not actioned by a GP, posing a risk to patient safety.
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classifier match
Committee recommendation
18match
#38 - 12th Report – Menstrual health of girls and young women
A key success of women’s health hubs is that they have facilitated co- commissioning of long-acting reversible contraception (LARC) by public authority sexual health services and NHS services. This can be an effective workaround for a dysfunctional LARC commissioning system that has been unfit for purpose since the Health and Social Care Act 2012 was introduced. Women’s health...
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classifier match
IMB recommendation
18match
Bronzefield (2024)
NHS England specifies the provision of face-to-face GP services, seven days a week. However, to date, this has not been achieved. How and when does NHS England intend to remedy this lack of provision? (6.1)
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classifier match
PHSO casework decision
18match
P-002352 - Devon Clinical Commissioning Group
Mrs O complains the CCG gave her son wrong advice about the commissioning of surgical correction for pectus excavatum (a condition where the breastbone sinks into the chest).
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classifier match
PHSO casework decision
18match
P-002619 - A dental practice in the Essex area
Mrs A went to the Practice in June 2023 after being referred by her dentist, to have two teeth removed. She says the Practice removed the wrong tooth without her consent.
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classifier match
LGO / SPSO decision
18match
22-002-725 - Leeds City Council
Summary: We will not investigate Mrs Y’s complaint about the care provided to her late grandmother, Mrs X. That is because further investigation would not lead to a different outcome, and we cannot achieve the outcome Mrs Y wants.
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classifier match
LGO / SPSO decision
18match
23-020-548a - Creative Support Ltd (23 020 548a)
Summary: Mr A has complained about a care agency and a Council after an investigation by the care agency into a pill found by carers at Ms B’s house. He said the investigation was inadequate and resulted in the care agency withdrawing care to Ms B. We did not investigate this case as we could not achieve more...
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classifier match
LGO / SPSO decision
14match
22-005-257 - Banks & Levett Limited
Summary: We will not investigate this complaint about damage to property because it is unlikely we could add to the Care Provider’s investigation or reach a different outcome. The Care Provider has made what appears to be a suitable offer to resolve the matter, the amount in dispute does not justify our involvement. Mrs B can make an...
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classifier match
LGO / SPSO decision
14match
22-001-210 - Thanet District Council
Summary: Mr X complained the Council wrongly refused him a Disabled Facilities Grant for adaptations to his home. He complained its decision was based on a flawed occupational therapy assessment and during a home visit to assess the adaptations, a council officer was rude to him. The Council was not at fault for its decision making around the...
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classifier match
LGO / SPSO decision
14match
22-001-944 - St. Judes Care Ltd
Summary: Mr B complains, on behalf of his father Mr C, that the Care Provider did not properly provide care for Mr C. The Care Provider took too long to reply to Mr B’s complaint and did not follow its complaints process properly. This did not cause Mr C any injustice.
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classifier match
LGO / SPSO decision
13match
21-018-599 - Chesterfield Borough Council
Summary: We will not investigate this complaint about Miss X’s transfer application and the assignment of her tenancy to her son. There is insufficient evidence of fault which would warrant an investigation. We cannot investigate complaints about tenancy matters concerning social housing landlords.
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