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
Source spread
Where this theme appears
Unclear healthcare delegation has been flagged across 8 independent accountability sources:
5 inquiry recs
21 PFD reports
8 committee recs
1 CQC action
2 IMB recs
1 patient safety alert
5 PHSO decisions
8 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (5)
IHRD-20 — Consultant-Led Ward Rounds
Recommendation: Children's ward rounds should be led by a consultant and occur every morning and evening.
Gov response: Consultant-led ward rounds implemented in children's wards.
Accepted
IHRD-15 — Consultant Notification on Admission
Recommendation: 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.
Gov response: Protocols implemented for consultant notification on unscheduled paediatric admissions.
Accepted
IHRD-12 — Senior Paediatric Responsibility
Recommendation: Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.
Gov response: Arrangements in place for senior paediatric oversight in children's wards.
Accepted
IHRD-21 — Nurse Attendance at Clinical Interactions
Recommendation: The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.
Gov response: Guidance issued on nurse attendance during clinical interactions with child patients.
Accepted
No update 2+ yrs
IHRD-19 — Senior Lead Nurse in Children's Wards
Recommendation: 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 …
Gov response: Senior lead nurse roles established in children's wards across Trusts.
Accepted
PFD Reports (21)
Violet Cloudsdale
Concerns: 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.
Overdue
Marjorie Nesbitt
Concerns: 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.
Response (Sheffield City Council): The council has prepared documents including a case study overview and practical advice for support workers, which it intends to share as a training tool with internal and commissioning services, …
Responded
Eleanor Brabant
Concerns: 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.
Overdue
Alexander Davidson
Concerns: 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.
Response (NHS England): NHS Pathways reviewed the question regarding dark brown or black vomit and concluded removing 'coffee-grounds' could result in over-referral. As part of routine review and governance procedures, they are conducting …
Response (National Institute for Health and Care Excellence): NICE will reconsider the scope of their guideline on pancreatitis (NG104) when it is next reviewed, to consider lipase/amylase testing in young people.
Overdue
Stanley Babbs
Concerns: 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.
Response (Barking, Havering and Redbridge University Hospitals NHS Trust): The Trust has implemented several actions to improve the safe use of IV contrast in CT scans, including communicating a new IV Contrast protocol, emphasizing the importance of personalized evaluations …
Responded
Amarbai Bhudia
Concerns: 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.
Response (Barts Health NHS Trust): Barts Health NHS Trust implemented a structured ward round template to improve communication and a teaching session on Nasogastric Tube Placement was delivered to teams on the wards. A comprehensive …
Overdue
Samantha Gould
Concerns: 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.
Response (NHS England): NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing …
Response (RPS): The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health …
Response (GPC): The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share …
Response (CCA): The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, …
Responded
Alison Dallow
Concerns: 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.
Overdue
Harold Wilberforce
Concerns: 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.
Response (General Pharmaceutical Council): The GPhC acknowledges receipt of the concern regarding Orchard 2000 Pharmacy and provides context about its role as a regulator of pharmacy professionals and premises, but does not describe any …
Response (General Pharmaceutical Council): The GPhC notes concerns about the roles and responsibilities of delivery agents and states that the Superintendent Pharmacist has updated SOPs to clarify how delivery drivers should respond to emergencies, …
Response (Orchard 2000 Pharmacy 1): Orchard 2000 Pharmacy has made delivery agents aware of their duty to contact emergency services and inform the pharmacist on duty in emergencies. They have also enrolled delivery agents in …
Responded
Christian Tuvi
Concerns: 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.
Response (Department for Transport): The Department for Transport acknowledges the coroner's concerns but states it has limited power to intervene and that the Office of Rail and Road and London Underground Limited are responsible. …
Response (Transport for London): Transport for London states that KONE engineers will undertake all inching activities on LU's moving walks and escalators. TfL is working with KONE to update Safe Systems of Work by …
Responded
Katherine Flynn
Concerns: 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.
Response (NHS England): NHS England will search reported incidents and undertake a thematic analysis regarding EVD incidents over the last three years to identify any additional cases or emerging themes to inform future …
Response (Society of British Neurological Surgeons): The SBNS asks its members to review or develop a Standard Operating Procedure (SOP) for EVD use, including an escalation plan for blocked EVDs, and offers to share a relevant …
Overdue
Catriona Martin
Concerns: 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.
Response (Aneurin Bevan University Health Board): The Health Board clarifies its position on delegation of nursing responsibilities to family members. They also report implementation of a digital platform for visibility of staffing levels and dissemination of …
Responded
Hannah Jacobs
Concerns: Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is needed on identifying anaphylaxis and using adrenaline auto-injectors if in doubt.
Response (NHS England): NHS England is reviewing its communications approach to alerting GP practices about medicine shortages and the Pharmacy and Medicines Optimisation Team is reviewing the use of AAIs and their supply. …
Response (BSACI): BSACI is developing an online allergy education platform for healthcare professionals and others, covering anaphylaxis recognition and management. The BSACI allergy action plans include difficulty swallowing as a manifestation of …
Response (Royal College of Physicians): The RCP will work with other colleges and societies to agree and support standards of care and education related to allergy, including updating standards for allergy accreditation and promoting multidisciplinary …
Response (General Dental Council): The GDC will write to NICE to suggest they review anaphylaxis symptoms and guidance for dental professionals, and will consider changes to CPD requirements regarding medical emergencies as part of …
Response (General Pharmaceutical Council): The GPhC acknowledges supply issues with adrenaline autoinjectors and highlights existing standards for pharmacy professionals, signposting other resources for safe AAI use and directing medicine supply inquiries to the DHSC. …
Response (Royal College of Paediatrics): The RCPCH will share information from the report with its members via a patient safety portal and for discussion with the Clinical Quality in Practice Committee, where further actions may …
Responded
Hannah Jacobs
Concerns: 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.
Response (Department of Health and Social Care): The DHSC refers to existing guidance on managing anaphylaxis in schools and the role of the Expert Advisory Group for Allergy, noting that adrenaline auto-injector suppliers were in stock at …
Overdue
Rachel Gibson
Concerns: Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Response (The Royal College of Anaesthetists): The Royal College of Anaesthetists will collaborate with surgical colleagues to improve local anaesthetic safety protocols and will include local anaesthetic toxicity secondary to surgical infiltration in their next National …
Responded
David Bennett
Concerns: 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.
Response (Mid South Essex NHS Trust): Mid South Essex NHS Trust is working with partners to develop clear and straightforward pathways for mental health care in the Emergency Department, with a rollout programme and training planned …
Response (Essex Partnership University NHS Trust): EPUT reports that the Mental Health Liaison team now has access to all key systems including SystmOne, and the Inpatient and Urgent Care Divisional Directors of Quality and Safety are …
Responded
Pamela Marking
Concerns: 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.
Response (NHS England): NHS England acknowledges concerns about public understanding of Physician Associates (PAs). It highlights the Leng Review of PA and AA professions, the establishment of PA title by law, and existing …
Response (Royal College of Emergency Medicine): The RCEM issued a position statement in June 2024 regarding Physician Associates which included supervised practice, public awareness, undifferentiated patients, and regulation. RCEM has worked with the national emergency laparotomy …
Response (CQC): The CQC acknowledges the coroner's concerns regarding Physician Associates and rapid sequence induction but states that some points are outside of their regulatory scope. They will ask the trust for …
Response (Department of Health and Social Care): DHSC acknowledges concerns regarding Physician Associates, rapid sequence induction, and guidelines. They highlight that healthcare professionals must practice within their competence. NHSE has issued guidance on the deployment of PAs …
Response (Association of Anaesthetists RCOA Difficult Airways Society): The Association of Anaesthetists and RCOA Difficult Airways Society address concerns raised and reference existing guidelines; they state that the topic of rapid sequence induction (RSI) is controversial and best …
Response (Surrey and Sussex NHS): Surrey & Sussex Healthcare NHS Trust acknowledges concerns regarding public understanding of Physician Associates, rapid sequence induction, and the use of cricoid pressure. It states PAs wear different coloured scrubs, …
Response (GMC): The GMC highlights its new powers to regulate PAs and AAs and states that it is developing website materials, due to be published in Spring, to support doctors who are …
Response (Royal College of Physicians): The RCP acknowledges concerns about the safe deployment of PAs and notes that the Faculty of Physician Associates was dissolved on 31 December 2024. It highlights concerns regarding regulation, scope …
Responded
Hailey Thompson
Concerns: 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.
Response (SSP Health and Ashton Medical Practice): SSP Health reinforced training for staff on the process to follow for prescription requests and highlighted their Access for Children Policy, stating that systems were in place at the time …
Response (Greater Manchester Integrated Care): NHS GM will ensure the practice carries out a Significant Event Analysis and key learning is implemented, and is working with locality leads to agree a more collective approach to …
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.
Response (The Riverside Group Limited): The Riverside Group plans to update its policies and procedures by September 2025 to improve communication and escalation processes when staff have concerns about a resident's welfare, particularly regarding medication …
Responded
Christopher O’Donnell
Concerns: 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.
Response (Home Group Limited): Home Group has introduced a virtual clinical hub, is reviewing and updating relevant policies, and is consulting with partner agencies on managing risks related to medication stockpiling. They have also …
Responded
Melanie Pinnell
Concerns: 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.
Response (Unity Healthcare): • Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based …
Responded
Committee Recommendations (8)
#83 — Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
Recommendation: The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with …
Gov response: The Government is grateful to the Education Select Committee for its inquiry report into Solving the SEND Crisis and we welcome the opportunity to respond to the Committee. Every child should have a childhood rich …
Not Addressed
#82 — Guidance on delegating healthcare responsibilities within schools remains weak and unclear.
Recommendation: 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 …
Gov response: The Government is grateful to the Education Select Committee for its inquiry report into Solving the SEND Crisis and we welcome the opportunity to respond to the Committee. Every child should have a childhood rich …
Not Addressed
#2 — Publish a clear definition of inclusive education with rationale and good practice examples.
Recommendation: 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 …
Gov response: As part of our Plan for Change, we are committed to reforming the SEND system to deliver an excellent, inclusive education for every child and young person with a world class curriculum and highly trained, …
Not Addressed
#1 — Absence of a departmental definition for inclusive education hinders clarity and investment planning.
Recommendation: 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, …
Gov response: As part of our Plan for Change, we are committed to reforming the SEND system to deliver an excellent, inclusive education for every child and young person with a world class curriculum and highly trained, …
Not Addressed
#41 —
Recommendation: 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 …
Response Pending
#40 —
Recommendation: 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 …
Response Pending
#39 —
Recommendation: 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, …
Response Pending
#38 —
Recommendation: 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 …
Response Pending
IMB Recommendations (2)
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?
HMPPS
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)
NHS / Healthcare Provider
National Patient Safety Alerts (1)
PHSO Casework Decisions (5)
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.
NHS in England
Partly Upheld
May 2024
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.
NHS in England
Partly Upheld
Dec 2025
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.
NHS in England
Dec 2023
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).
NHS in England
Partly Upheld
Dec 2023
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.
NHS in England
May 2024
LGO / SPSO Decisions (8)
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 …
LGO (Local Government & …
Adult Care Services
Upheld
May 2025
25-009-869a — Clarity Homecare (Bristol) (25 009 869a)
LGO (Local Government & …
Health
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.
LGO (Local Government & …
Adult Care Services
Jul 2022
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 …
LGO (Local Government & …
Adult Care Services
Jun 2024
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 …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
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 …
LGO (Local Government & …
Adult Care Services
Not Upheld
Sep 2022
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 …
LGO (Local Government & …
Adult Care Services
Not Upheld
Nov 2022
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.
LGO (Local Government & …
Housing
Apr 2022