Urgent care pathways
Deficiencies in urgent care pathways for serious but non-immediately life-threatening conditions, leading to delays and poor outcomes.
296 items
10 sources
1 inquiry
Source spread
Where this theme appears
Urgent care pathways has been flagged across 10 independent accountability sources:
2 inquiry recs
230 PFD reports
8 committee recs
6 CQC actions
28 PPO recs
13 IOPC recs
1 PHSO rec
4 IMB reports
1 PHSO decision
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 (2)
MAI-77 — Review procedures for patient dispatch to hospitals
Recommendation: North West Ambulance Service should review its procedures with local NHS trusts to ensure that it has effective policies in place for quickly dispatching patients injured in a Major Incident to an appropriate hospital.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-149 — Healthcare provision under Protect Duty
Recommendation: The Home Office should consider whether the requirement for adequate healthcare provision at events is a topic that should also be addressed by the Protect Duty.
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
PFD Reports (230) — showing 50 strongest matches
Dorothy Townley
Concerns: Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides context on its role, training, and advice to members, highlighting relevant sections of the GP Curriculum related to communication between professionals and patient …
Responded
Barnabas Newlyn
Concerns: Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
Response (NHS England): NHS England will issue interim guidance on protocols for time-sensitive critical care transfers, offer training to critical care staff in retrieval, mobilise commissioning arrangements for standardising protocols, and commission a …
Responded
Chloe Grace Flavell
Concerns: The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Overdue
Andrew John Fallon
Concerns: Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Overdue
Albert James Hand
Concerns: The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews in the Luton and Bedfordshire area, and protocols for dealing with emergency calls potentially putting patients at risk.
Response (East of England Ambulance Service NHS Trust): The East of England Ambulance Service NHS Trust has reviewed its Demand Management Plan, commenced issuing a clinical manual to staff, and is commissioning an upgrade to the Computer Aided …
Responded
Jacqueline Allwood
Concerns: The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.
Response (NHS England): NHS England has requested that the GP in question undertake a reflective report, attend a course on medical record keeping, and complete an audit of his medical record keeping, with …
Overdue
Keith Martin
Concerns: Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.
Overdue
Selina Broadhurst
Concerns: Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury diagnoses in frail elderly patients.
Overdue
Peter Galea
Concerns: Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting patients to a place of safety for detailed assessment.
Overdue
Keith Thomas Graham
Concerns: The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning contraindications, and minimising time to surgery when indicated.
Overdue
James Sutton
Concerns: The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.
Overdue
Stephen Palmer
Concerns: Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.
Overdue
Stephen Bedford
Concerns: Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Overdue
Gianna Khan
Concerns: The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead of being seen by a doctor in the A&E Department, and that the Clinical Commissioning Group had refused a full triage before streaming patients.
Response (Luton NHS Clinical Commissioning Group): Luton CCG will share findings with Luton Clinical Commissioning Group, LHS has accepted NICE Guidance CG176, LHS will cooperate with NHS England investigation and is resubmitting its 'Risk and Serious …
Responded
Thomas Smith
Concerns: Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.
Overdue
Mary Hallworth
Concerns: A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.
Overdue
Kirk Williams
Concerns: A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack of dialogue and clear guidelines.
Response (South Tees Clinical Commissioning Group): Multiple CCGs and Trusts report that if a detainee has a known past mental health history, they should be taken to the 136 unit at Roseberry Park; if serious concerns …
Response (Cleveland Police): Cleveland Police provides annual Personal Safety Training to all front-line officers, including training on "excited delirium." The police, along with medical directors and A&E consultants, established new guidelines for aggressive …
Response (NHS England): NHS England will consider the case further with the Northern Regional Medical Director to determine whether changes need to be made to relevant policies and guidance, including liaison with Public …
Overdue
Sandra Bodrozic
Concerns: Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.
Overdue
Lara Mamula
Concerns: The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.
Overdue
Anthony Huggan
Concerns: The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.
Response (Bury Council): The council provides contextual information about commissioned substance misuse services and describes the services available, but does not outline specific changes in response to the concerns.
Responded
Mikey Hornby
Concerns: The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked essential diagnostic facilities.
Response (Bridgewater Community Healthcare NHS Trust): Bridgewater Community Healthcare NHS Foundation Trust has taken several actions, including updating the Out of Hours Triage Policy, developing a Paediatric Early Warning System (PEWS) and escalation aid, and delivering …
Responded
Kevin Hoey
Concerns: The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients in the community or transfer them to hospital.
Response (East of England Ambulance Service): East of England Ambulance Service is reviewing the East Midlands Ambulance Service's Paramedic Pathfinder Programme to determine its potential implementation within the Trust and implications for current training.
Responded
Noel Jones
Concerns: Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.
Response (Worcestershire NHS Trust): The Trust has reviewed its out-of-hours arrangements for vascular surgery/interventional radiology for critically ill patients needing transfer.
Responded
Patricia Chapman
Concerns: Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.
Response (County Durham and Darlington NHS Trust): The Trust has trained qualified staff at Sedgefield Community Hospital in managing deteriorating patients and hypoglycemia. They have introduced an operational procedure for community hospital staff to seek urgent advice …
Responded
Sally Ellison
Concerns: There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.
Response (NHS Wales): NHS Wales, through the Pathology Clinical Programme Group, has reviewed the process for requesting urgent samples from primary care and is distributing a memorandum to GPs and Practice Managers with …
Responded
George Boulton
Concerns: Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke as an immediate emergency, risking critical treatment windows.
Response: East Midlands Ambulance Service acknowledges the coroner's concerns and explains their current processes for urgent patient transfers. NHS England describes a broader review of urgent and emergency care and the …
Overdue
Anne Wilson
Concerns: Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical information not being acted upon or shared with the requesting GP.
Response (London Ambulance Service NHS Trust): A Control Services Bulletin will be issued by the end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient …
Overdue
Robert Hogg
Concerns: NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns and provides context about NHS Pathways and SCAS, deferring to the NHS Pathways response for specific actions.
Response (NHS Pathways): NHS Pathways disputes the coroner's concerns, arguing that the system was used correctly and that no similar cases had been reported. They request the allegations be struck from the record …
Responded
James Adams
Concerns: A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable consultant time.
Response (NHS England): • Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group (CCG) to develop a pathway for local implementation of guidance for thromboprohylaxis in ambulatory patients requiring temporary …
Response (James Adams): • The working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up. • Kernow CCG …
Responded
Caroline Robey
Concerns: Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities and delayed emergency admission.
Response (NHS England): NHS England discussed the case at a Performance Advisory Group and requested reflection on record keeping and sepsis diagnosis/treatment in the next appraisal. The importance of diagnosing sepsis and the …
Response (ROBEY Responses): A patient safety alert was issued, and the CCG will meet with the University Hospitals of Leicester to share experience/materials and provide support in sepsis management. A clinical newsletter was …
Overdue
Steven Jackson
Concerns: A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
Overdue
Christine McNamara
Concerns: There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a Maidstone surgical consultant for urgent referrals.
Response (Maidstone and Tunbridge Wells NHS Trust): The trust implemented a new pathway in January 2016 for managing patients who develop post-endoscopic surgery complications, with a review scheduled for October 2016.
Responded
Leslie Summerfield
Concerns: The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating their conditions.
Overdue
Michael Valentine
Concerns: Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were not marked urgent nor accompanied by a phone call.
Response (Michael Valentine): The practice conducted audits of post and electronic communication review procedures and found them to be robust. They also met with Second Care Psychiatry colleagues to discuss the rejection process …
Response (Michael Valentine Response2): The organization will ensure staff that reject an urgent referral will contact the referrer directly to confirm the outcome. They will seek advice from the Local Medical Committee to ask …
Responded
Douglas Kay
Concerns: There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.
Response (DBH Trust): The Trust developed an Upper GI Bleed Transfer Policy for Bassetlaw Hospital after consultation between anaesthetic and medical teams. Staff will be made aware of the policy, and it will …
Responded
David Mostari
Concerns: Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted outside of weekdays.
Response (D Mostari): The Trust developed and implemented a position statement/action plan to ensure a robust system for urgent tests and imaging, including publicizing service details on the trust intranet and extending pharmacy …
Responded
Sandra Wood
Concerns: The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.
Response (sandra wood): The Trust states they do have facilities to provide CT scans during weekends and that scans are carried out on all patients that require them, based on a clinical decision; …
Responded
Marilyn Anson
Concerns: Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.
Overdue
Eric Gaskell
Concerns: Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy hours.
Response (Eric Gaskell): The hospital will review the existing stock list of over-labelled and pre-packed medicines with the Accident and Emergency Department by 31 May 2016. They also plan to advertise the opening …
Responded
Vanessa Dadswell
Concerns: Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.
Response (Vanessa DADSWELL): The triage system has been improved with direct bookable Priority Appointment slots for Triage Team Leaders and senior staff oversight. A protocol encompassing the improved system is being drafted throughout …
Overdue
June Parkes
Concerns: Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.
Overdue
Pamela Conway
Concerns: Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital …
Response: The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group.
Responded
Harry Gill
Concerns: The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Response (NHS England): NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the …
Responded
Imad Hassan
Concerns: There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.
Response (Hassan): Cwm Taf University Health Board has been working to develop an interim solution pending the completion of a comprehensive pathway in the summer of 2017. A local corrective Action Plan …
Response (Imad Hassan): The United Hospitals University Bristol Trust will accept patients if there is insufficient critical care capacity in South Wales, facilitated by the regional PPCI centre. Work is underway on an …
Overdue
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
Teresa Dennett
Concerns: Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as critical concerns. A lack of defined protocols risked delayed treatment for patients needing urgent surgery.
Response (Nottingham University Hospitals NHS Trust): A new protocol for the transfer of patients requiring life-saving surgery has been written and shared with relevant stakeholders. The protocol has been published online and all critical care units …
Response (Sheffield Teaching Hosipals NHS): Sheffield Teaching Hospitals NHS is finalising and communicating a local protocol for the admission of patients requiring emergency neurosurgical procedures, based on SBNS guidelines. This will be shared with trusts …
Response (NHS England): NHS England sought assurance from Specialised Neurosurgical Centres and referring hospitals that protocols are in place to ensure patients requiring life-saving surgical intervention will be referred regardless of critical care …
Overdue
Terence Millington
Concerns: Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.
Response (Sheffield Teaching Hospital NHS Trust): Sheffield Teaching Hospital NHS Trust has discussed the incident with the doctor concerned and included reference to on-call responsibilities in the local induction program. An emergency epistaxis bag is now …
Responded
Ceriann Richards
Concerns: Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.
Response: Aneurin Bevan University Health Board describes steps taken to address ambulance handover issues, including establishing an Urgent Care Board, implementing a Standard Operating Procedure for bed management, and introducing 'Breaking …
Response (Welsh Government): The Welsh Government acknowledges concerns about handover delays and outlines existing initiatives by the Welsh Ambulance Services NHS Trust to limit conveyance rates, including an enhanced clinical desk, alternative pathways, …
Responded
Frederick Bevan
Concerns: A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking detrimental effects on treatment.
Overdue
Derek Turnbull
Concerns: There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.
Overdue
Committee Recommendations (8)
#10 — Establish a 24/7 Neighbourhood Mental Health Centre in every community.
Recommendation: We believe there should be a 24/7 Neighbourhood Mental Health Centre in every community. (Recommendation, Paragraph 92)
No Published Response
#6 —
Recommendation: We therefore recommend that NHS England completes and publishes evaluations of NHS 111 call first services as soon as is practicable, including learning from those evaluations and the implications for any future iterations of the service.
Gov response: The NHS is committed to evaluating services to ensure that they are providing high quality care for patients. NHS England is currently undertaking further detailed analysis of the NHS 111 First programme. We expect the …
Under Consideration
#5 —
Recommendation: Managed well, we see enormous potential for a beefed-up version of 111 to regulate the demands on emergency departments and ensure that patients get the right care, in the right place, at the right time. However, we acknowledge concerns that …
Gov response: NHS England are evaluating the NHS 111 First service, and a final evaluation report will be published in due course. This will assess the impact of the service on emergency departments and patient outcomes.
Under Consideration
#1 — Evidence taken from DHSC and NHS England on access to unplanned or urgent care.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) and NHS England about access to unplanned or urgent care.1
Gov response: The government agrees with the Committee’s recommendation. improving patient flow through hospitals, with plans to boost capacity with 5,000 extra core General and Acute beds. In addition to this, NHS England is working with systems …
Accepted
#3 — Clearly set out causes of urgent care performance variation and initiatives to improve standards.
Recommendation: The quality of patients’ access to urgent and emergency care depends too much on where they live, particularly with wide variation in ambulance response times. There is significant regional variation in the performance of services for urgent and emergency care. …
Gov response: The government agrees with the Committee’s recommendation. improvements to Emergency Departments and ambulance performance requires working between secondary, primary, community and social care so the Urgent and Emergency Care (UEC) tiering support offer is taking …
Accepted
#4 — Ensure all FGM survivors access timely, essential support and specialist care nationwide
Recommendation: The Government should ensure that all FGM survivors can access the essential support and care they need in a timely manner. While some variation in service provision may be necessary to reflect local prevalence rates, higher-prevalence areas should offer funded …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Accepted
#32 — Need for Integrated Care Systems to simplify patient interface and improve first-contact access.
Recommendation: Integrated Care Systems should prioritise simplifying the patient interface with the NHS by improving access, triage and referral across first-contact NHS organisations including general practice.
Gov response: Accept. The Department accepts this recommendation and agrees that this should be a priority for Integrated Care Systems. NHS England have already issued a framework to support conversations between Integrated Care System teams and GP …
Accepted
#31 — Unacceptable patient uncertainty accessing first-contact care through new NHS organisations.
Recommendation: Primary Care Networks and Integrated Care Systems offer an opportunity to better integrate care around people. It should not be the case that patients face so much uncertainty about where to turn to if they have a new or urgent …
Gov response: Accept. The Department accepts this recommendation and agrees that this should be a priority for Integrated Care Systems. NHS England have already issued a framework to support conversations between Integrated Care System teams and GP …
Accepted
CQC Inspection Actions (6)
Waterbeach Surgery
Continuetomonitorandimprovepatientexperiencerelatingtoaccesstothesurgery.
Should Do
Psychiatry-UK LLP
The service must ensure that risks associated with providing care and treatment out of hours and led by consultants outside of the UK are consistently and effectively managed.
Must Do
TOB Care services Ltd
People's needs and choices were not delivered in line with standards, guidance and the law. People were not supported to access appropriate healthcare services. People did not receive person-centred care and support.
Must Do
Billet Lane Medical Practice
Considerreviewingunplannedadmissionstosecondarycare.
Should Do
St Clare's Hospice
The provider should review and access and flow within the hospice to ensure patients access care and treatment at the right time.
Should Do
The Moat House
We recommend the provider seek advice and guidance from a reputable source, about supporting people to manage their oral hygiene and access dental practices.
Should Do
PPO Death in Custody Recommendations (28)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are fully aware of and understand their responsibilities in a medical emergency, including the use of an emergency response code if a prisoner has chest pains and documenting incidents.
The Governor and the Head of Healthcare
mental health and/or general nurses are called to assess concerns about prisoners’ health and well-being, and
The Governor
The Governor should ensure that when a clinician advises that a prisoner should be sent to hospital: • the policy of referring such decisions to the duty governor is rigorously enforced and; • where the advice is not followed, the …
The Head of Healthcare
The Head of Healthcare should ensure that in a medical emergency, the patient is moved to an appropriate area where they can be fully assessed and treated.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who are unwell and require clinical monitoring are reviewed overnight.
The Head of Healthcare
The Head of Healthcare should ensure there is a robust policy for the delivery and follow up of FIT tests and their results, and that patients who decline to engage are offered a face-to-face appointment with a GP to discuss.
The Governor
The Governor should ensure that control room staff accurately communicate the location of an incident and request an ambulance as soon as an emergency code is radioed.
The Head of Healthcare
The Head of Healthcare should ensure that where there are serious concerns about the health of a prisoner, staff use an emergency code to summon assistance and alert control room staff to call an ambulance immediately, in line with Prison …
The Head of Healthcare
The Head of Healthcare should ensure that: staff know how to escalate if a further on-site clinical assessment is not available at the desired time.
The Head of Healthcare
The Head of Healthcare should ensure that: staff are able to decide if an urgent appointment demands an immediate response;
The Governor
The Governor should ensure that all staff understand their responsibilities during a medical emergency, and in particular that: officers fully understand the expectation that preservation of life must take precedence when considering entering a locked cell whether at night or …
The Head of Healthcare
The Head of Healthcare should ensure that prisoners presenting with chest pain are managed in line with NICE guidelines on the diagnosis of chest pain and, where indicated, referred for emergency treatment.
The Head of Healthcare
The Head of Healthcare should ensure that there is: • Adequate training for nurses responsible for assessing the clinical condition and appropriate treatment pathways for prisoners, and • At least one nurse trained in advanced clinical assessment skills during all …
The Head of Healthcare
The Head of Healthcare should address the high number of “Code Calls” by: • Introducing an “Urgent Assessment” system whereby a prison officer can request a same day assessment to be undertaken by a Registered Nurse; and • Implementing an …
The Head of Healthcare
The Head of Healthcare should ensure that: • the welfare check sheet used for monitoring prisoners suspected to be under the influence of a substance includes timescales for review, escalation and transfer to hospital; and that • training is provided …
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of the Multi-Professional Complex Case Clinic (MPCCC) criteria and consider its early use for a patient who is deteriorating.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a MUST assessment when a person is weighed and ensure any concerns are escalated with immediate effect.
The Head of Healthcare
The Head of Healthcare should ensure that when patients are presenting with red flag symptoms an urgent chest X-ray is ordered under the 2-week guidelines and in accordance with NICE Guidelines NG12 suspected cancer: recognition and referral.
The Head of Healthcare
The Head of Healthcare should ensure that there is a robust process in place for the review of healthcare applications to ensure a timely review by the most appropriate member of the healthcare team.
The Approved Premises Manager
ensure that staff err on the side of caution and call an ambulance immediately when a resident is found unresponsive and may have taken drugs;
The Head of Healthcare
The Head of Healthcare should ensure that, once an emergency code blue has been called and an ambulance is on the way, staff should only stand it down if they are confident that the patient has fully recovered.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should formalise the way that PS incidents are assessed and the handover of care from healthcare to prison staff including: • The development and introduction of a PS assessment template for SystmOne, to include …
The Head of Healthcare
The Head of Healthcare should ensure that all staff receive appropriate training in differential diagnosis pathways, and all pathways are considered when attending an emergency response.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a suitable location where a prisoner can receive short-term 24-hour nursing care if required.
The Head of Healthcare
The Head of Healthcare should ensure that there is always a registered nurse or a GP present during a medical emergency. Guidance on the role of GPs and senior managers during an emergency should be developed, detailing guidance on leadership, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare staff have entry to prisoner’s cells on K Wing at the weekend, to allow face to face clinical assessments when required.
The Head of Healthcare
The Head of Healthcare should review the use of the NHS 111 service to determine whether there is a need to extend the provision of prison GPs.
NHS England and SECAmb
NHS England and SECAmb should conduct an investigation into the circumstances surrounding Mr Dawes-Clarke’s resuscitation, including the actions of paramedics in attendance.
IOPC Learning Recommendations (13)
Recommendations - Gwent Police, February 2021
The IOPC recommends that Gwent Police engages with external agencies, who regularly request the police to conduct welfare checks on their behalf, and establishes a Memorandum of Understanding. This is to ensure that both the agencies and Gwent Police are …
Recommendations - Gwent Police, February 2021
The IOPC recommends that Gwent Police creates a detailed question set for call handlers responding to requests from external agencies to conduct welfare checks. The prompts should help call handlers to elecit key information during a conversation to help inform …
Investigation into police contact with a man following a report into his …
The IOPC recommends that Merseyside Police ensures that there is a robust agreement in place between the force and North West Ambulance Service NHS Trust in relation to people who come into contact with the police and require urgent medical …
Recommendations - Sussex Police, March 2020
If such a situation arises, a review should take place after proactive measures to allocate responsibility have been taken, as opposed to at the material time of the patient being absent in order to avoid delay in resourcing a response. …
Recommendations - Nottinghamshire Police, January 2021
The IOPC recommends that Nottinghamshire Police provide training to ensure that control room operatives ensure that the Threat, Harm, Risk, Investigation, Vulnerability, Engagement (THRIVE) risk assessment is appropriately endorsed on all SAFE incident logs. A review of a number of …
Recommendations - Nottinghamshire Police, January 2021
The IOPC recommends that Nottinghamshire Police provides guidance for their control room operatives so that they are clearly aware of the minimum set of standards which highlight the information should be included in SAFE incident logs for individuals suffering from …
Recommendation - North Yorkshire Police, August 2023
The IOPC recommends that North Yorkshire Police should take steps to satisfy itself that, in line with Authorised Professional Practice, officers and members of police staff understand how to identify the signs that a person is drunk and incapable. Such …
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police should work with Cumbria, Northumbria Tyne and Wear NHS (CNTW) to review and revise the referral points discussed in the Street Triage Team (STT) Operational Policy document around when a member of the public …
Recommendations - Sussex Police, March 2020
The Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts …
Recommendations - Sussex Police, November 2023
The IOPC recommends that Sussex Police develop an escalation process to be adopted in the event that a call has been passed to the Ambulance Service but the Ambulance Service is unable to resource the call. This process should be …
Recommendation – Greater Manchester Police, November 2023
The IOPC recommends that Greater Manchester Police implements essential changes to ensure the Greater Manchester Mental Health Tactical Advice Service (MHTAS) are being utilised by response officers and call handlers during mental health incidents. These changes should include: Amending the …
Police contact with man prior to his death - Lancashire Constabulary, June …
The IOPC recommends that Greater Manchester Police (GMP) and Lancashire Constabulary should create a joint protocol on how to manage cross-border Grade 1 immediate and Grade 2 priority incidents. This follows an IOPC investigation where there were concerns for a …
Recommendation - Cambridgeshire Constabulary, May 2024
The IOPC recommends that Cambridgeshire Constabulary liaises with the local authority to request access to any resource list they may have regarding organisations that can provide transport for individuals who use a wheelchair of any size. The force should ensure …
PHSO Ombudsman Recommendations (1)
IMB Annual Reports (4)
Heathrow and City airports Short Term Holding Facilities (2021)
The reporting period was significantly impacted by the Covid-19 pandemic, leading to concerns about infection control, longer detainee stays, and increased waiting times. Key issues included slow implementation of effective Covid-19 measures, inability for detainees to access personal medication, and inadequate hygiene and family facilities in some terminals. Despite these challenges, Detention Custody Officers were observed to be largely kind and courteous.
PRISON
Key concerns
Haverigg (2024)
HMP Haverigg, a Category D open prison for men, maintained low levels of self-harm and violence, with two deaths in custody. The Board commended efforts to improve facilities and provide high-standard healthcare for an increasingly elderly and complex population, despite some staff vacancies. Key concerns included challenges for ex-PCoSO prisoners in finding employment, difficulties securing accommodation on release, and prisoners' reluctance to raise complaints due to perceived negative consequences.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2024)
The IMB's annual report for Kent Coast STHF (Kent Intake Unit, Western Jet Foil, Manston, and Frontier House) highlights continuous operations processing a high volume of arrivals. While commending staff's empathetic approach and noting no self-harm or assault incidents, the Board raises significant concerns about privacy during interviews, inadequate isolation facilities, and insufficient information provided to detainees about their onward journey. It recommends improvements in communication, facility maintenance, and welfare provision for unaccompanied children.
PRISON
Key concerns
Derwentside (2024)
The IMB report for Derwentside IRC highlights a generally safe environment and positive staff interactions despite significant staff churn and the planned re-roling of the centre. However, key concerns persist regarding the centre's remote location and poor communications infrastructure, contributing to inhumane treatment via long, disruptive journeys for detainees. While healthcare provision is praised, unacceptably long waits for Rule 35(3) assessments and reduced activity provision for wellbeing remain critical issues, alongside ongoing dissatisfaction with food and the lack of a detention time limit.
PRISON
Key concerns
Health Investigations (3)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 3a
Welsh Government should progress at pace in 2026 with commissioning and implementation of the national triage line and publish a standardised national model for in person triage.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 4c
A review of clinical pathways for rare but serious pregnancy-related conditions, to ensure clear, consistent and commissioned routes to expert care within Wales or, where required, across the UK.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 3b
A national service specification should be developed to ensure consistent alignment with evidence-based guidance on informed decision-making, care planning and timely access to care. This should include a standardised service model setting out admission pathways, place of care, dedicated staffing, and routine consideration of induction capacity and flow within daily …
wales
Accepted