First reported 15 Dec 2015•Latest report 31 Mar 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to safe equipment-use instructions, including provision, availability, clarity, completeness, identification of defect or hazard indications, user understanding, and monitoring or assurance of compliance, across clinical, industrial, recreational and other operational equipment.
Not included
Excludes generic training, supervision, documentation or compliance deficiencies that are not specifically tied to safe equipment-use instructions.
Excludes equipment defects, maintenance or certification failures where no instruction or instruction-compliance control is deficient.
Excludes clinical, referral, care or operational protocols that do not govern the safe use of equipment.
Excludes failures concerning the operation of a particular piece of equipment when the report does not identify an equipment-use instruction or compliance-control deficiency.
Reports
22
Distinct published reports
Individual concerns
26
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
53
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care3
Medicines and Healthcare products Regulatory Agency3
NHS England3
Abbeyfield The Dales Limited1
Agd Equipment Limited1
Birmingham City Council1
Boc Limited1
British Standards Institution1
Broomcroft House Care Home1
Bupa Care Homes (AKW) Limited1
Bureau Veritas UK Limited1
Care Quality Commission1
Civil Aviation Authority1
Construction Plant-hire Association1
Department for Work and Pensions1
Private limited company9
Ministerial department5
Executive non-departmental public body3
Medicines and medical devices regulator3
NHS trust3
Trade association2
Aviation regulator1
Domiciliary care provider1
English metropolitan district council1
English unitary authority1
Fire and rescue service1
Health and social care service regulator1
Healthcare site1
Health-system partnership1
London borough council1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Newcastle upon Tyne and North Tyneside
Concerns raised2
Failure to restrict wheelchair use to mobility when no safe alternative seating was available
Failure to follow mobility-only wheelchair advice and provide safe general seating
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There were no reasonable grounds to suspect an offence under Regulations 12 and 22, so formal criminal investigation was not undertaken.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Yorkshire (Western)
Concerns raised2
Lack of instructions on the circumstances for using specific prescribed equipment
Lack of monitoring of compliance with equipment-use instructions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.15
Action
Use the new care plan format to document mobility equipment, operating procedures and equipment changes, with monthly completeness and accuracy checks.
Stated by Abbeyfield The Dales LimitedStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Action
Record new mobility equipment, images and correct-use instructions in residents’ care plans, including instructions supplied by health professionals.
Stated by Abbeyfield The Dales LimitedStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Action
Implement a process clarifying new equipment use, circumstances, staff accountability and competency checks for equipment introduced by health professionals.
Stated by Abbeyfield The Dales LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Revise moving-and-handling assessment templates to identify the assessed equipment task and require advice before use outside that scope.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Use the revised templates in NYCC’s case-recording system and remind occupational therapists to adopt them.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Use a practice review meeting to reinforce clarity about the intended task when moving-and-handling plans are completed and shared.
Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Action
Notify equipment prescribers through the ICES newsletter about the new moving-and-handling templates.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Require care-provider contracts to specify that prescribed equipment is used for its assessed purpose and that changes are reflected in care plans.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Share and reinforce correct equipment, moving-and-handling-plan, and care-plan practices through care-provider forums, bulletins, and online events.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Reinforce with ICES the contractual requirement to supply equipment with instruction leaflets.
Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Action
Request that ICES make equipment instruction leaflets retrievable from its database for occupational therapists.
Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Action
Introduce dedicated occupational-therapy training on completing moving-and-handling assessments and plans, incorporating learning from the inquest.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Deliver specialist moving-and-handling training for NYCC occupational therapists focused on equipment purpose and moving-and-handling plans.
Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
Action
Conduct unannounced Quality Manager spot-check audits of care plans and observed care practice to verify compliance with equipment-use instructions and address improvements.
Stated by Abbeyfield The Dales LimitedStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Action
Conduct standardized service delivery audits comparing care delivered with care plans, and follow up deficiencies through supervision, retraining or closer performance monitoring.
Stated by Abbeyfield The Dales LimitedStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Monitoring compliance with equipment-use instructions is assigned to Abbeyfields the Dales rather than North Yorkshire County Council.
Stated by North Yorkshire CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised1
Lack of transformer warning signage requiring confirmation of adequate oil before use
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Attach prominent oil-level and carbon-monoxide warning stickers to all transformers, instructing users not to energise without sufficient oil.
Stated by Hirst Electrical PHS (UK) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The company considers its documented transformer safety changes sufficient to satisfy the notice and does not identify further necessary work.
Stated by Hirst Electrical PHS (UK) Ltd.No action considered necessaryThe respondent said that no further action was needed.
Wiltshire and Swindon
Concerns raised1
Failure of the emergency fuel-primer-pump instructions to specify the required cycle rate
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Discuss YAK fuel-primer-pump use during power loss at the next CAA-led YAK and Nanchang Continuing Airworthiness Forum and consider whether additional UK guidance would be useful and effective.
Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Requesting the manufacturer to specify a fuel-primer-pump rate is not appropriate because technical and human factors may make use counterproductive.
Stated by Civil Aviation AuthorityNo action considered necessaryThe respondent said that no further action was needed.
North Northumberland
Concerns raised1
Lack of manufacturer guidance on automatic gearbox use during long downhill descents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Automatic gearbox mode is not generally likely to exacerbate brake fade during long descents.
Stated by Volvo Group UK LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The current manual's instruction to use the retarder when driving downhill is sufficient; no gearbox-mode recommendation is needed.
Stated by Volvo Group UK LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester West
Concerns raised1
Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Newcastle upon Tyne
Concerns raised2
Remounting of the valve contrary to the manufacturer’s instructions for use
Lack of awareness among the primary surgeon and operating team of the risks of departing from the manufacturer’s instructions for use
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cumbria
Concerns raised1
Lack of ward-based systems to ensure compliance
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Inadequacy and inaccuracy of safety guidance for internal-combustion-engine equipment used in confined or enclosed areas
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Inadequate advice and guidance on insulin pump misuse dangers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Review user manuals and training materials in response to the inquest evidence and identified safety concerns.
Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 27 July 2016.
Action
Issue and distribute a Field Safety Notice reinforcing correct insulin-cartridge insertion instructions and associated misuse risks.
Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 27 July 2016.
Action
Update pump training sessions using the new Training Handling chart to reinforce correct insulin-cartridge insertion instructions.
Stated by Recipient name withheldStated in progressThe respondent said that this action was in progress when they made their response on 27 July 2016.
Action
Incorporate the Field Safety Notice’s reinforced cartridge-insertion instructions into the product manual supplied with new pumps.
Stated by Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 27 July 2016.
Action
Review how to support greater uptake and consistency of structured education, including content on incorrect pump use and hyperglycaemia management.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 July 2016.
Action
Ensure health boards’ insulin pump services meet NICE safety standards, including annual education updates.
Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 27 July 2016.
Action
Conduct a further risk assessment of the insulin pump safety message.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 27 July 2016.
Action
Disseminate reinforced cartridge-changing instructions through a Medical Device Alert, press release and National Medical Device Safety Officers’ Webex.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 27 July 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing information and training adequately explain insulin-pump misuse risks, hyperglycaemia management and cartridge insertion consequences.
Stated by Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Training healthcare professionals and patients is outside the respondent’s remit; manufacturers and healthcare providers have related instructional and training responsibilities.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
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Includes failures of controls specifically dedicated to safe equipment-use instructions, including provision, availability, clarity, completeness, identification of defect or hazard indications, user understanding, and monitoring or assurance of compliance, across clinical, industrial, recreational and other operational equipment.
