First reported 23 May 2013•Latest report 2 May 2025
Definition
What this concern includes
Includes deficiencies in complaint-handling processes where complaints or concerns about safety are not reliably accepted, read, recorded, triaged, investigated, progressed, kept under review or responded to, including failures to take statements, investigate next-of-kin concerns, handle service complaints or communicate outcomes.
Not included
Excludes generic incident investigations, disciplinary investigations or post-death investigations unless the asserted deficiency concerns handling a complaint or safety concern raised through a complaint process.
Excludes ordinary dissatisfaction or complaints with no identified safety-related handling deficiency.
Excludes generic communication, documentation, staffing or training deficiencies unless they directly impair the complaint-handling process.
Excludes failure to act on a safety hazard or care concern where no complaint-handling failure is identified.
Reports
13
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
33
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.
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
British Army1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Derbyshire Constabulary1
East London NHS Foundation Trust1
European Care & Lifestyles (UK) Limited1
Greater London Authority1
Home Office1
London Borough of Islington1
Ministry of Housing, Communities and Local Government1
Ministry of Justice1
NHS England1
NHS Wales1
Peabody Trust1
Ministerial department3
NHS trust3
Local health board2
Care-home operator1
English county council1
Executive non-departmental public body1
Health-system partnership1
Local authority1
London borough council1
Multi-service care provider1
Police force1
Prison or young offender institution1
Registered charity1
Registered provider of social housing1
Sub-organisation1
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.
Inner West London
Concerns raised1
Failure to listen to and sufficiently investigate concerns and complaints raised by next of kin
This report raised 6 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.5
Action
Conduct quarterly anonymous Family Satisfaction Surveys and use their findings in governance-led service improvements.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Operate a monthly senior-leader Family Forum, document themes, and monitor agreed actions.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Create a Clinical Governance Department and a senior role championing children’s and families’ experiences.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Revise the complaints policy and process to address gaps and align with national best practice.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Introduce a modified escalation procedure enabling families to request a second opinion or further care review.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
North West Kent
Concerns raised2
Lack of a formal complaint procedure for recording, investigating and communicating outcomes
Failure to appropriately deal with complaints about unsafe driving standards
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.2
Action
Use a documented complaint procedure requiring recorded meetings, investigation updates, outcomes and manager referral through a standard flow chart.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Run a weekly multidisciplinary Driving Standards Review Panel to assess concerns, determine outcomes and monitor repeated concerns.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A documented driving-concerns mechanism exists, so the premise that no formal complaint procedure is in place is disputed.
Stated by South East Coast Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Formal complaint response timescales are not set because they depend on the nature of the response required.
Stated by South East Coast Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Northumberland
Concerns raised1
Failure to read and consider patient complaint forms during handling and triage
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.1
Action
Provide clinician support when reception staff raise patient concerns, including clinical review of written material where appropriate.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Immediate opening and triage of complaint forms handed to receptionists cannot be implemented because of confidentiality issues.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to act on resident complaints about the barrier
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The Regulator of Social Housing assessed Peabody against regulatory standards and concluded that no further regulatory action was required.
Stated by Ministry of Housing, Communities and Local GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Peabody considered it unable to block or alter the barrier because it lacked ownership rights and understood planning conditions prohibited obstructing waterfront access.
Stated by Peabody TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Peabody sought the Council’s assistance because it understood the Council or CRT/CIC held responsibility for the barrier and Dock Wall.
Stated by Peabody TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing improvements to complaints systems, processes and culture mean no additional changes to the complaints system and processes are currently required.
Stated by Peabody TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Swansea and Neath Port Talbot
Concerns raised1
Failure to conduct robust, transparent and timely formal complaint investigations
This report raised 6 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.3
Action
Review clinical-review processes with involved clinicians within seven working days to support complaint investigations and reflection on care.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
Action
Review the standard operating protocol for coordinating complaints and patient-safety incidents and identifying shared learning.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
Action
Conduct quarterly reviews of serious-incident investigations and complaints to ensure coordinated, timely progression under the relevant processes.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.
Stated by Welsh GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North West Wales
Concerns raised1
Inadequate systems and processes for responding to urgent complaints and concerns
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.
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.3
Action
Operate the revised Complaints Procedure, including an escalation process.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Review incident and complaint processes and create an integrated framework covering incidents, complaints and mortality.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Action
Roll out the Call 4 Concern service to general hospital sites, providing patients and families access to urgent clinical support.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Derby and Derbyshire
Concerns raised1
Failure to investigate stalking complaints fully and in line with available guidance
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.13
Action
Refresh stalking training content to cover risk indicators, reasonable enquiries, pattern analysis, ongoing risk assessment and record keeping.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Deliver revised mandatory stalking training to frontline officers and staff, monitor attendance, evaluate it and include it in continuing professional development.
Stated by Derbyshire ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Update student-officer training products to incorporate current stalking guidance and learning from the report.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Review stalking resources and issue messages raising staff awareness of their availability for investigations.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Publish a stalking policy and supporting standard operating procedure with investigation checklists and expectations for pattern analysis and reasonable enquiries.
Stated by Derbyshire ConstabularyStated plannedThe respondent said that this action was planned when they made their response on 1 December 2023.
Action
Operate Quality Assurance Thematic Testing to audit investigations, provide feedback and signpost relevant guidance and policy.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Conduct stalking-focused crime audits and scrutinise performance outcomes through force performance meetings.
Stated by Derbyshire ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Undertake an independent peer review of stalking policies, procedures and training materials with the National Police Chiefs’ Council lead.
Stated by Derbyshire ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Conduct a further thematic audit of stalking investigations and review its findings through the strategic Performance Assurance Board.
Stated by Derbyshire ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Deliver investigative-mindset workshops and embed robust record-keeping requirements in the improvement strategy, with governance and QATT monitoring.
Stated by Derbyshire ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Raise police awareness of available stalking guidance and training through regular work with the National Police Chiefs’ Council.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Review statutory guidance on coercive and controlling behaviour to clarify its differences from stalking.
Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 1 December 2023.
Action
Gather policing best-practice examples on stalking cases and share them with forces to support stalking policies.
Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 1 December 2023.
South Yorkshire (Western)
Concerns raised3
Failure to share primary care complaint review information back to practices for learning
Failure to ensure that primary care complaint clinical reviews are fully informed by relevant information
Failure to cascade relevant primary care complaint review information to the primary care network
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.2
Action
Update the complaints policy to require sharing final responses with concerned providers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 January 2023.
Action
Remind all regional complaints teams to share final responses with concerned providers under the complaints policy.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Routine information sharing with Primary Care Networks is not required because established locality, ICB and national processes support appropriate complaint learning.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Failure to ensure defect inspectors receive recent road-condition complaints
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
Build a new data system and assess whether historical complaint data should be made available to highway inspectors.
Stated by Surrey County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Limited resources and inconsistent public reporting mean inspections cannot be redirected or biased solely by the number of complaints received.
Stated by Surrey County CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Berkshire
Concerns raised1
Insufficient awareness of how to handle service complaints within the army
This report raised 4 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.3
Action
Raise awareness of service complaints through policy, publications, outreach, education and mandated annual training, including welfare signposting.
Stated by ArmyStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2021.
Action
Simplify service-complaint terminology to improve users’ understanding of the process.
Stated by ArmyStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
Action
Deliver service-complaint management training and presentations to relevant Army courses, formations and personnel.
Stated by ArmyStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2021.
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Includes deficiencies in complaint-handling processes where complaints or concerns about safety are not reliably accepted, read, recorded, triaged, investigated, progressed, kept under review or responded to, including failures to take statements, investigate next-of-kin concerns, handle service complaints or communicate outcomes.
