2023/24 review: Shortfalls
When we inspect an establishment, we assess the premises, review their records, operational policies and procedures, and observe practices. We also conduct interviews and roundtable discussions with a range of staff. By assessing establishments in this way, we can identify whether they are compliant with our standards and – where they are not met – assess the criticality of any shortfalls.
We categorise shortfalls as minor, major or critical against a total of 353 licensing standards (noting that some standards span multiple sectors). In 2023/24, we identified 757 shortfalls across 226 inspections and worked with our licensed establishments to identify the steps they needed to take to meet our standards.
Number of shortfalls per sector
Sector | Number of standards | Minor | Major | Critical | 2023/24 total | 2022/23 total | 2021/22 total |
72 | 207 | 253 | 8 | 468 | 648 | 363 | |
Human application | 121 | 174 | 18 | 0 | 192 | 288 | 337 |
Research | 47 | 73 | 0 | 0 | 73 | 91 | 37 |
Anatomy | 47 | 19 | 0 | 0 | 19 | 21 | 14 |
Organ donation and transplantation | 30 | 4 | 1 | 0 | 5 | 3 | 3 |
Public display | 36 | 0 | 0 | 0 | 0 | 3 | 0 |
Total | 353 | 477 | 272 | 8 | 757 | 1,054 | 754 |
We took immediate action when we found critical shortfalls to address areas of concern. This involved being directive about what an establishment should do to correct the shortfall. Where we found major or minor shortfalls, we worked (or continue to work) with establishments to ensure they achieved full compliance in a timely manner through an agreed corrective and preventative action (CAPA) plan.
…improvement suggestions are common sense, pragmatic, and have improved safety. As soon as we have the conversation with the HTA it just makes sense. … – it’s a conversation, a realisation of how [things are supposed to] work.
[The HTA] has a way [of driving up standards] that is working with the establishment rather than being antagonistic.
Back to the 2023/24 review contents page