Mid Staffordshire NHS Foundation Trust Public Inquiry

It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work; Each such organisation should announce at the earliest practicable time its decision on the extent to which it accepts the recommendations and what it intends to do to implement those accepted, and thereafter, on a regular basis but not less than once a year, publish in a report information regarding its progress in relation to its planned actions; In addition to taking such steps for itself, the Department of Health should collate information about the decisions and actions generally and publish on a regular basis but not less than once a year the progress reported by other organisations; The House of Commons Select Committee on Health should be invited to consider incorporating into its reviews of the performance of organisations accountable to Parliament a review of the decisions and actions they have taken with regard to the recommendations in this report.

The Inquiry recommended that healthcare bodies publish regular progress updates on implementing its findings. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the government and other relevant organisations had published reports responding to each recommendation and updating on progress (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in February 2026 that the government accepted the recommendation, cataloguing published responses and progress updates across central government, regulators, and royal colleges (The Thirlwall Inquiry legal team, Feb 2026).

The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: A common set of core values and standards shared throughout the system; Leadership at all levels from ward to the top of the Department of Health, committed to and capable of involving all staff with those values and standards; A system which recognises and applies the values of transparency, honesty and candour; Freely available, useful, reliable and full information on attainment of the values and standards; A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system.

The Inquiry asked the NHS to adopt a shared culture prioritising patient care. The Department of Health and Social Care (DHSC) and NHS England, in commentary of September 2024, published in February 2026, described action on shared core values, leadership development, and cultural measurement tools (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation and outlined past measures on leadership, inspection standards, and the statutory duty of candour (The Thirlwall Inquiry legal team, May 2024).

The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common values, as well as the respective rights, legitimate expectations and obligations of patients.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that implementation was complete, noting that the NHS Constitution was updated in August 2023 and healthcare providers are required under standard contract terms to take account of it in their decisions (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that Health Education England maintained a values hub to support understanding of the constitution alongside earlier guidance on patient feedback (The Thirlwall Inquiry legal team, May 2024).

The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by this ethos.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and ongoing, referring to their responses to earlier recommendations (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team reported that the government accepted the recommendation, noting that the department updated the NHS Constitution in March 2013 to state that “patients come first in everything we do” and amended it further in July 2015 (The Thirlwall Inquiry legal team, Feb 2026).

In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; They will do everything in their power to protect patients from avoidable harm; They will be honest and open with patients regardless of the consequences for themselves; Where they are unable to provide the assistance a patient needs, they will direct them where possible to those who can do so; They will apply the NHS values in all their work.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, referring to their response to earlier recommendations (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that following a July 2015 government consultation response, these expectations had been included in the NHS Constitution under staff responsibilities (The Thirlwall Inquiry legal team, May 2024).

The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance.

The Department of Health and Social Care and NHS England reported in February 2026 that the recommendation was implemented, stating that the handbook to the NHS Constitution in England was updated in October 2023 to give prominent focus to NHS values and their significance (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that revised handbooks published in March 2013 and July 2015 set out and explained the values in their first substantive section (The Thirlwall Inquiry legal team, May 2024).

Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers are commissioned to provide services.

In commentary published in February 2026, the Department of Health and Social Care and NHS England described implementation as ongoing, stating that the NHS Standard Contract requires providers to abide by staff pledges in the NHS Constitution and that contracted services remain subject to fundamental standards enforced by the Care Quality Commission (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been accepted and that contract revisions had been reported by the government (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in February 2015 that the action was completed after the 2014/15 contract required providers to ensure all subcontractors abide by the constitution (Department of Health, Feb 2015).

Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional disagreements about procedures must be required to take the necessary corrective action, working with their medical or nursing director or line manager within the trust, with external support where necessary. Professional bodies should work on devising evidence-based standard procedures for as many interventions and pathways as possible.

In February 2026, the Department of Health and Social Care and NHS England reported that the government had enacted legislation establishing fundamental standards as registration requirements for the Care Quality Commission, and that the regulator had worked with healthcare professionals and Royal Colleges in developing its approach (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and cited the introduction of fundamental standards under 2014 regulations alongside professional engagement during the regulatory process (The Thirlwall Inquiry legal team, May 2024).

Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.

The Inquiry asked healthcare providers to insist on incident reporting and give staff feedback. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that national guidance specifies mandatory and encouraged incident recording through the Learn from Patient Safety Events (LFPSE) service, but feedback to staff was not mentioned (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team reviewed the recommendation, noting past government updates on incident reporting metrics and system recommissioning (The Thirlwall Inquiry legal team, May 2024).

Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. There should be a defined set of duties to maintain and operate an effective system to ensure compliance; Enhanced quality standards – such standards could set requirements higher than the fundamental standards but be discretionary matters for commissioning and subject to availability of resources; Developmental standards which set out longer term goals for providers – these would focus on improvements in effectiveness and are more likely to be the focus of commissioners and progressive provider leadership than the regulator. All such standards would require regular review and modification.

The Inquiry recommended dividing healthcare standards into fundamental, enhanced quality, and developmental tiers. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the Care Quality Commission (CQC) can take civil enforcement action or bring criminal prosecutions against providers breaching fundamental standards, alongside wider requirements set through provider licences and the NHS Oversight Framework (2024) (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that twelve fundamental standards took effect in April 2015 under 2014 regulations, while enhanced quality standards and developmental statements were incorporated into guidance from the National Institute for Health and Care Excellence (NICE) (The Thirlwall Inquiry legal team, May 2024).

The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the fundamental standards which should define outcomes for patients that must be avoided. These should be limited to those matters that it is universally accepted should be avoided for individual patients who are accepted for treatment by a healthcare provider.

In September 2024, the Department of Health and Social Care and NHS England stated that the recommendation was implemented through the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as amended, which established fundamental standards setting the level below which care must not fall (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that these standards had taken effect under the regulations in April 2015 following consultations by the government and the Care Quality Commission (The Thirlwall Inquiry legal team, May 2024).

It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and in the means of measuring compliance.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that professional regulators regularly consult their registrants and other stakeholders when formulating standards, coordinate through the Joint Strategic Oversight Group, and align quality across health and care via the National Quality Board (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and summarised previous updates on the Care Quality Commission involving healthcare professionals in inspections and joint agreements (The Thirlwall Inquiry legal team, May 2024).

The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.

The Inquiry recommended developing evidence-based safe staffing tools and organisational culture measures. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the National Institute for Health and Care Excellence (NICE) continues to issue guidance on positive working cultures, while NHS England has published safe staffing improvement resources across several service settings (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team noted that NICE published safe staffing guidance for acute wards and maternity settings before suspending its safe staffing programme in June 2015 (The Thirlwall Inquiry legal team, Feb 2026).

Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted by the public and healthcare professionals.

In February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission’s assessment approach continued to evolve while always linking back to fundamental standards, especially regarding enforcement action (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and cited the commission’s public engagement on fundamental standards (The Thirlwall Inquiry legal team, May 2024). Earlier, in February 2015, the department reported that the commission had published provider handbooks describing inspection and rating processes ahead of fundamental standards coming into force in April 2015 (Department of Health, Feb 2015).

It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, to develop measures of outcome in relation to their work and to assist in the development of measures of standards compliance.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented, with 99 percent of trusts enrolled in the National Consultant Information Programme, but noted that the platform is not in the public domain and establishing a single repository remains dependent on integrating private healthcare data (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation and recorded prior work to develop outcome measures (The Thirlwall Inquiry legal team, May 2024).

In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake in-depth investigations where these appear to be required.

The Inquiry recommended that regulators prioritise direct observation, interaction, and record audits over reviewing policies. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the Care Quality Commission (CQC) continues to emphasise observation, staff feedback, and care experiences, though the update did not mention record audits or in-depth investigations (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had reported the introduction of pre-inspection listening events, staff interviews, and time spent with service users (The Thirlwall Inquiry legal team, May 2024).

The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, unless there is evidence showing that suspicions are ill-founded or that deficiencies have been remedied. It requires a focus on identifying what is wrong, not on praising what is right.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission makes enforcement decisions in accordance with its published enforcement policy and decision tree, while also having regard to the Code for Crown Prosecutors for any prosecutions (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that although regulations made certain breaches prosecutable without prior warning notices, the government had not explicitly stated what threshold would be used or whether and how a no-tolerance approach would be adopted (The Thirlwall Inquiry legal team, May 2024).

Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals are responsible. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow and failure to disclose breaches of these standards to the affected patient (or concerned relative) and a regulator should also attract regulatory consequences. Breaches not resulting in actual harm but which have exposed patients to a continuing risk of harm to which they would not otherwise have been exposed should also be regarded as unacceptable.

The Inquiry recommended zero tolerance, regulatory sanctions, and criminal liability for breaches of fundamental standards. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England pointed to the Care Quality Commission (CQC) enforcement policy, the NHS Oversight Framework, and the Recovery Support Programme replacing special measures (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in its February 2026 review that regulations make breaches prosecutable without warning notices and empower the regulator to refuse registration, recommend intervention, or prosecute when patients face harm or significant risk (The Thirlwall Inquiry legal team, Feb 2026).

It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has been served and the notice has not been complied with. It should be a defence for the provider to prove that all reasonably practicable steps have been taken to prevent a breach, including having in place a prescribed system to prevent such a breach.

The Inquiry recommended creating a criminal offence when regulatory breaches cause patient death or serious injury. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission (CQC) can prosecute providers without a prior warning notice under regulations introduced in 2014 (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in May 2024 that regulations made breaches prosecutable where avoidable harm or significant risk occurred, with a defence available if providers took all reasonable steps (The Thirlwall Inquiry legal team, May 2024).

The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach of fundamental standards, even if it has yet to reach a concluded view or acquire all the evidence. The test should be whether it has reasonable grounds in the public interest to make the interim requirement or recommendation.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and ongoing, pointing to the Care Quality Commission's enforcement policy (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation, observing that the regulator retained statutory powers to halt unsafe care alongside warning notices introduced under the Care Act 2014 (The Thirlwall Inquiry legal team, May 2024).

Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place policies which ensure that they constantly review whether the need to protect patients requires use of their own powers of intervention to inform a decision whether or not to intervene, taking account of, but not being bound by, the views or actions of other regulators.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that Monitor had merged with NHS England, noting that System Quality Groups share intelligence across integrated care systems and the Recovery Support Programme replaced special measures (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and reviewed earlier government updates regarding oversight frameworks, quality surveillance, and intervention powers (The Thirlwall Inquiry legal team, May 2024).

Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary measures to ensure such protection while any investigation required to make a final determination is undertaken.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was superseded, noting that the Care Quality Commission can use civil and enforcement powers to suspend or cancel registrations alongside the NHS Patient Safety Incident Response Framework (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team observed that the government had accepted the recommendation, noting earlier reports on regulatory intervention powers under the special measures regime (The Thirlwall Inquiry legal team, May 2024).

Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work should be done on a template of the sort of information each organisation would find helpful.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care reported alongside NHS England that predecessor regulatory functions had merged under a single oversight framework focused on collaborative working and information sharing with the Care Quality Commission (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team reviewed the recommendation, summarising previous official updates on Quality Surveillance Groups and regulator memoranda of understanding without assessing implementation as complete (The Thirlwall Inquiry legal team, May 2024).

A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk of non-compliance. It must not only include statistics about outcomes, but must take advantage of all safety related information, including that capable of being derived from incidents, complaints and investigations.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that implementation was ongoing, highlighting coordinated data collections such as the NHS Federated Data Platform, Care Quality Commission Insight tools, and the Learn from patient safety events service (DHSC and NHS England, Feb 2026). In its review published in February 2026, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation, summarising earlier progress updates from 2014 and 2015 regarding national data systems (The Thirlwall Inquiry legal team, Feb 2026).

Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to set out detail, this should be made available via each trust's website. Reports should no longer be confined to reports on achievements as opposed to a fair representation of areas where compliance has not been achieved. A full account should be given as to the methods used to produce the information. To make or be party to a wilfully or recklessly false statement as to compliance with safety or essential standards in the required quality account should be made a criminal offence.

The Inquiry recommended trusts report compliance accurately in quality accounts and criminalise false statements. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that section 92 of the Care Act 2014 created an offence for care providers supplying false or misleading statutory information, while trusts must publish quality accounts annually subject to regulator corrections (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that NHS guidance requires every quality account to include a declaration signed by the organisation's most senior manager confirming its accuracy (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local relationship managers. Any bureaucratic or legal obstacles to this should be removed.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was superseded, explaining that the Care Quality Commission gathers evidence on complaints through ongoing assessments and retains statutory powers to compel providers to share details (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the commission had previously integrated complaints information into its surveillance and inspection planning processes (The Thirlwall Inquiry legal team, May 2024).

It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.

In February 2026, the Department of Health and Social Care and NHS England reported that work on the recommendation was ongoing, highlighting the NHS Complaint Standards and statutory regulations that require annual complaints reports to include narrative (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted earlier accounts of the Care Quality Commission using focus groups, interviews, and planned audits of sample complaints files to assess complaints handling during inspections (The Thirlwall Inquiry legal team, May 2024).

Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.

The Department of Health and Social Care and NHS England stated in September 2024 that the recommendation had been superseded, explaining that serious untoward incidents no longer exist following the transition to the Patient Safety Incident Response Framework (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had previously accepted the recommendation and reported routine incident sharing through regional groups and monitoring tools (The Thirlwall Inquiry legal team, May 2024).

Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission's national media and regional engagement team conducts regular media monitoring, with its operations teams following up directly when coverage suggests people may be at risk (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and cited previous government reporting on the regulator's review of how it used media intelligence (The Thirlwall Inquiry legal team, May 2024).

The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation had been superseded because the Care Quality Commission had transitioned to a Single Assessment Framework, while noting that an interim review had highlighted areas needing operational improvement (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and replaced the quality and risk profile approach with sector-wide risk indicator analyses and revised inspection procedures (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission works with foundation trust governors on appointment, highlighting an updated provider code of governance and dedicated governor support programmes (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted, recording earlier government reports on developing guidance and sharing information with overview and scrutiny committees (The Thirlwall Inquiry legal team, May 2024).

Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from Local Healthwatch; New or existing peer review schemes; Themed inspections.

In September 2024, the Department of Health and Social Care and NHS England reported that the recommendation had been superseded, explaining that the Care Quality Commission's Single Assessment Framework enables inspectors to monitor risk continually through ongoing feedback and data rather than relying solely on on-site inspections (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded previous government updates describing the commission's introduction of intelligent monitoring and strategic thematic inspections (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission gathers evidence both on site and off site, maintaining on-site observation to assess care quality (DHSC and NHS England, Feb 2026). They stated that the commission carries out on-site activity more frequently where services present greater risks of undetected poor culture or where concerns exist regarding transparent evidence (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and highlighted the commission's specialist inspection regime (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, including service user representatives, clinicians and any other specialism necessary because of particular concerns. Consideration should be given to applying the same principle to the independent sector, as well as to the NHS.

In February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission retains specialist inspectors across hospitals, mental health, primary care, and adult social care within regional integrated assessment and inspection teams, while internal work reviewing the split between inspectors and assessors remains ongoing (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation and noted the introduction of three Chief Inspector roles alongside multidisciplinary inspection teams (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission conducts joint local authority area inspections with partner inspectorates including Ofsted, involves the health service body in trust-level well-led assessments, and notes external review principles produced by the Academy of Royal Medical Colleges (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team observed in May 2024 that while the commission had entered joint working protocols with the Nursing and Midwifery Council and the General Medical Council, only the nursing protocol explicitly referenced aligned visits and inspection activity (The Thirlwall Inquiry legal team, May 2024).

Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.

The Department of Health and Social Care and NHS England stated in September 2024 that the Care Quality Commission's regulatory approach has evolved from routine onsite inspections to assessments informed by intelligence and data, while retaining onsite inspections when risks warrant (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and committed to fundamental reform and greater independence rather than abolishing the regulator (The Thirlwall Inquiry legal team, May 2024).

Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.

In February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission records all decision-making meetings and actions, with minutes also taken for joint work involving the National Quality Board (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the measure was accepted and recorded that partnership agreements to formally record meetings had been established with bodies including the Local Government Ombudsman and the Parliamentary and Health Service Ombudsman (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.

The Department of Health and Social Care and NHS England reported in February 2026 that the Care Quality Commission had phased in a single assessment framework from November 2023, but noted that operational reviews remained ongoing, with further updates awaiting unpublished reviews by Mike Richards and the final Penny Dash review (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been completed, noting that an evaluation of the regulator's inspection approach was published in September 2018 (The Thirlwall Inquiry legal team, May 2024).

The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.

In September 2024 commentary published in February 2026, DHSC and NHS England recorded this recommendation as superseded, referring to their response to recommendation 55 in relation to the Dash review (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and found that the Care Quality Commission "appears to continue to publish 3-year strategies" following earlier consultations on its regulatory framework (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of the first inquiry, and open that evaluation for public scrutiny.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented, stating that Keiran Walshe evaluated the Care Quality Commission's approach in 2014 and that the commission developed its monitoring framework largely in response to the Mid Staffs review (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted the recommendation, observing that the government had accepted it and had reported the regulator's creation of indicator sets and an Intelligent Monitoring system (The Thirlwall Inquiry legal team, May 2024).

Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient perspective directly.

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission still retains its Experts by Experience programme (DHSC and NHS England, Feb 2026). Reviewing progress in May 2024, the Thirlwall Inquiry legal team noted that while user representatives had been involved through inspections and board membership, "it is unclear whether a patient’s consultative council or panel was ever constituted" (The Thirlwall Inquiry legal team, May 2024).

For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.

In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England reported that Monitor had merged into the latter body, which hosts an assembly of patient representatives and issued guidance in 2023 on statutory public involvement duties (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that implementation remained unconfirmed, having reviewed the government's previous progress updates (The Thirlwall Inquiry legal team, May 2024).

Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.

In February 2026, the Department of Health and Social Care and NHS England stated that Monitor had been abolished and its functions transferred, noting that although statutory authorisation powers remain, "no more FTs are being authorised" (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been accepted, noting previous government confirmation that side letters had been published since 2011 alongside quarterly risk ratings (The Thirlwall Inquiry legal team, May 2024).

The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.

In February 2026, the Department of Health and Social Care and NHS England stated that although foundation trust authorisation powers remain following the abolition of Monitor, the "policy position has changed and no more FTs are being authorised" (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and that the NHS Trust Development Authority had published an accountability framework requiring proof of care quality before foundation trust bids could proceed (The Thirlwall Inquiry legal team, May 2024).

The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust for foundation trust status and in particular on whether a potential applicant is delivering a sustainable service compliant with fundamental standards; An accessible record of responses received is maintained; The responses are made available for analysis on behalf of the Secretary of State, and, where an application is assessed by it, Monitor.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation had been superseded, explaining that while statutory powers remain, the "policy position has changed and no more FTs are being authorised" (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and reviewed the consultation and assessment arrangements originally proposed by the NHS Trust Development Authority and Monitor (The Thirlwall Inquiry legal team, May 2024).

The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service delivered to patients, and the sustainability of a service at the required standard.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation had been superseded, explaining that statutory authorisation powers remain but the "policy position has changed and no more FTs are being authorised" (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the NHS Trust Development Authority had established an accountability framework requiring applicants to demonstrate fundamental standards of clinical quality and patient experience (The Thirlwall Inquiry legal team, May 2024).

No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied that the organisation currently meets Monitor's criteria for authorisation and that it is delivering a sustainable service which is, and will remain, safe for patients, and is compliant with at least fundamental standards.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was superseded, noting that following the abolition of Monitor and the transfer of its functions, "no more FTs are being authorised" (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and that the NHS Trust Development Authority had established an accountability framework requiring trusts to baseline their quality, safety, and sustainability (The Thirlwall Inquiry legal team, May 2024).

The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with the financial and corporate governance requirements of a foundation trust.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was superseded, stating that following the abolition of Monitor and the transfer of functions, the "policy position has changed and no more FTs are being authorised" (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and outlined previous accountability frameworks requiring applicant trusts to demonstrate clinical quality and safety (The Thirlwall Inquiry legal team, May 2024).

A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant information material to the application and to ensure that any information is complete and accurate. This duty should continue throughout the application process, and thereafter in relation to the monitoring of compliance.

The Department of Health and Social Care and NHS England stated in commentary published in February 2026 that following the abolition of Monitor and the transfer of its functions, the policy position changed and "no more FTs are being authorised" (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation, requiring applicant trust leaders to confirm full disclosure and enacting an offence for false or misleading information under the Care Act 2014 (The Thirlwall Inquiry legal team, May 2024).

The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a service to patients which is, at the time of his consideration, safe, effective and compliant with all relevant standards, and that in his opinion it is reasonable to conclude that the proposed applicant will continue to be able to do so for the foreseeable future. In deciding whether he can be so satisfied, the Secretary of State should have regard to the required public consultation and should consult with the healthcare regulator.

In commentary from September 2024, the Department of Health and Social Care and NHS England stated that while statutory powers to authorise foundation trusts remain, the "policy position has changed and no more FTs are being authorised" (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in February 2026 that the government had accepted the recommendation and previously delegated applicant assessments to the NHS Trust Development Authority (The Thirlwall Inquiry legal team, Feb 2026).

The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether it is compliant with fundamental safety and quality standards.

In February 2026, the Department of Health and Social Care and NHS England referred to their response to Recommendation 63 rather than providing a separate update (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation, noting that the Care Quality Commission had agreed to inspect trusts during the foundation trust application process (The Thirlwall Inquiry legal team, May 2024).

The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate degree of clarity of understanding of the scope of their respective responsibilities has been maintained.

In February 2026, the Department of Health and Social Care and NHS England reported that Monitor had become part of NHS England, regular accountability meetings were held under a framework agreement, and recommendations to enhance oversight of the Care Quality Commission had been acted on (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and used standard accountability processes to keep relationships with arm's length bodies under regular review (The Thirlwall Inquiry legal team, May 2024).

Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation to account to the public, and in particular in arranging for communication with the public served by the foundation trust and to be informed of the public's views about the services offered.

DHSC and NHS England stated in commentary of September 2024, published in February 2026, that the recommendation was implemented and closed, noting that Monitor had merged with NHS England and an updated reference guide for governors was produced in 2022 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted, citing guidance previously published by Monitor and GovernWell on representing the interests of the public and foundation trust members (The Thirlwall Inquiry legal team, May 2024).

Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive contact between governors and the public is maintained.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that an addendum published in 2022 explains how foundation trust councils of governors should interact regularly with members and the public (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation while determining that definitions of how governors engage the public should be agreed locally between boards and governors rather than set in law (The Thirlwall Inquiry legal team, May 2024).

Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust's services.

In September 2024, the Department of Health and Social Care and NHS England stated that the recommendation had been implemented, reporting that NHS Providers leads the national GovernWell training programme and that an updated governance code issued in April 2023 requires foundation trust governors to receive appropriate induction and ongoing skill refreshes (DHSC and NHS England, Feb 2026). In an overview published in February 2026, the Thirlwall Inquiry legal team noted the acceptance of the recommendation and the code requirements, without marking the measure as fully implemented (The Thirlwall Inquiry legal team, Feb 2026).

The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in relation to compliance with healthcare standards as will be available for compliance issues in relation to breach of a licence (pursuant to section 39A of the National Health Service Act 2006 as amended), or other ready access to external assistance.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented, explaining that the Care Quality Commission produced guidance for foundation trust governors in 2019 and that GovernWell continues to provide a governor support programme (DHSC and NHS England, Feb 2026). Prior to this, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted by the government, recording earlier steps by Monitor to establish an advisory panel for governors in 2013 (The Thirlwall Inquiry legal team, May 2024).

Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.

The Inquiry recommended setting minimum experience or training standards within director fitness criteria. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that regulations and Care Quality Commission (CQC) guidance require directors to hold necessary qualifications, competence, skills, and experience (DHSC and NHS England, Feb 2026). They added that NHS England published a competency framework in February 2024 to support fitness assessments, though recognition of equivalence was not mentioned (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and relied on governance codes regarding relevant director skills (The Thirlwall Inquiry legal team, May 2024).

Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is no longer a fit and proper person, regardless of whether the trust is in significant breach of its authorisation or licence.

DHSC and NHS England stated in February 2026 that a decision had been made not to pursue statutory regulation of individual directors beyond existing duties, but noted that the scope of further implementation would need to be considered following a commitment to bring managers into regulation (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the Care Quality Commission had not been given powers to bar or directly regulate individual directors, leaving trusts to act upon the fit and proper person test (The Thirlwall Inquiry legal team, May 2024).

If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would exercise its power to require the removal or suspension or disqualification of directors who did not fulfil it, and the procedure it would follow to ensure due process.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was superseded, noting that Monitor had merged with the latter (DHSC and NHS England, Feb 2026). They stated that the fitness requirement had been enacted under 2014 regulations, the Care Quality Commission had issued guidance, and a framework had been published on applying the test for directors (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the government accepted the recommendation and that the commission had provided guidance on how it would apply the test (The Thirlwall Inquiry legal team, May 2024).

Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found to have been guilty of serious failure in the performance of his or her office, and in particular with regard to the need to have regard to the public interest in protection of patients and maintenance of confidence in the NHS and the healthcare system.

In February 2026, the Department of Health and Social Care and NHS England stated that implementation was complete, referring to the Fit and Proper Performance Test Framework and Board Leadership Competency Framework (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the Care Quality Commission had published guidance on the application of the fit and proper persons test, with service misconduct included as a ground of unfitness (The Thirlwall Inquiry legal team, May 2024).

A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that an updated April 2023 code of governance requires directors to receive induction, regularly refresh their skills, and access trust-funded training, with an independent evaluation of a new board competency framework planned for 2025 (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation and cited previous guidance on board training (The Thirlwall Inquiry legal team, May 2024).

In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires individuals or organisations to be brought to account for their failings, the Health and Safety Executive should obtain expert advice, as is done in the field of healthcare litigation and fitness to practise proceedings.

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, referring back to the government response and highlighting a memorandum of understanding between the Health and Safety Executive and the Care Quality Commission (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation, recording its earlier statement that the executive had always sought expert advice and that the commission would seek specialist advice when investigating potential breaches of fundamental standards (The Thirlwall Inquiry legal team, May 2024).

The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.

In February 2026, DHSC and NHS England stated that the NHS Litigation Authority, now NHS Resolution, had moved away from assessment against risk management standards, having introduced a Maternity Incentive Scheme in 2017 that offers indemnity contribution reductions for meeting ten safety actions (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation, observing that 2013 pricing changes had replaced risk management discounts with financial rewards for trusts with fewer and less costly claims (The Thirlwall Inquiry legal team, May 2024).

As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.

The Department of Health and Social Care and NHS England stated in February 2026 that the recommendation was implemented and closed, reporting that a best practice guide had been published in 2021 to help trusts learn from negligence claims (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation was implemented, noting the extranet service launched by the NHS Litigation Authority during 2013 and 2014 to provide trusts with real-time claims data and learning resources (The Thirlwall Inquiry legal team, May 2024).

As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given to allowing the Care Quality Commission access to these reports.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, stating that NHS Resolution shares relevant information as part of the Care Quality Commission's inspections regime (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been implemented, citing earlier reporting that information was shared under the regulator's inspection regime (The Thirlwall Inquiry legal team, May 2024).

The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which can be placed on them.

The Department of Health and Social Care and NHS England stated in September 2024 that the recommendation was complete, explaining that the former NHS Litigation Authority had published an explanation of the limitations of its assessment process on its website and had moved away from assessing against standards (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had recorded that the website explanation had been provided (The Thirlwall Inquiry legal team, May 2024).

While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer review inspections or the inclusion in Patient Environment Action Team representatives from outside the organisation. Consideration could also be given to involvement from time to time of a representative of the Care Quality Commission.

The Inquiry recommended external peer reviews and outside representation on hospital inspection teams. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported hosting Patient-led Assessments of the Care Environment involving local people, with independent reviewers considered best practice, but did not mention Care Quality Commission representation (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and that patient-led assessments with at least 50% patient or public membership had replaced earlier inspection teams (The Thirlwall Inquiry legal team, May 2024).

Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others facilitated in that task.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that incident data held as successor to the National Patient Safety Agency was open to analysis through routes including the Learn from Patient Safety Events service (DHSC and NHS England, Feb 2026). They noted that this service remained in a public-beta stage, with intentions to launch a new public dashboard (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team reviewed implementation, noting prior government updates on making incident data available to researchers and regulators (The Thirlwall Inquiry legal team, May 2024).

The National Patient Safety Agency or its successor should regularly share information with Monitor.

In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was superseded, as the National Patient Safety Agency no longer exists and it is the successor to both that agency and Monitor (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and cited earlier government reporting on data sharing (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in February 2015 that the recommendation was completed, recording that monthly data-sharing arrangements had been established in April 2014 (Department of Health, Feb 2015).

The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying areas for focusing its attention. There needs to be a better dialogue between the two organisations as to how they can assist each other.

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England stated that patient safety incident reports are provided to the Care Quality Commission (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and cited earlier updates regarding joint safety work between both organisations (The Thirlwall Inquiry legal team, May 2024). The department had previously reported the recommendation completed in February 2015, stating that the commission had secured free access to incident reporting information collected across national systems (Department of Health, Feb 2015).

Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that mortality information from various sources, including incident reporting and the Summary Hospital-level Mortality Indicator, should be triangulated under the Learning from Deaths policy (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and summarised previous work on proposals for retrospective case note reviews of patient deaths across trusts (The Thirlwall Inquiry legal team, May 2024).

The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health and Social Care Information Centre.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the UK Health Security Agency now collects and publishes data on hospital and community acquired infections by NHS organisation, with records for some infections dating back to 2013 (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation alongside earlier reports that Public Health England had published mandatory surveillance figures and developed integrated data systems (The Thirlwall Inquiry legal team, May 2024).

If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients or public safety, they should immediately inform all responsible commissioners, including the relevant regional office of the NHS Commissioning Board, the Care Quality Commission and, where relevant, Monitor, of those concerns. Sharing of such information should not be regarded as an action of last resort. It should review its procedures to ensure clarity of responsibility for taking this action.

DHSC and NHS England stated in September 2024 that the recommendation was implemented on an ongoing basis, reporting that health protection functions had transferred to the UK Health Security Agency and that a statutory Code of Practice on infection prevention was issued in 2022 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted earlier government progress updates and an April 2013 memorandum of understanding between Public Health England and the Care Quality Commission (The Thirlwall Inquiry legal team, May 2024).

Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection control arrangements.

The Department of Health and Social Care and NHS England stated in commentary published in February 2026 that the UK Health Security Agency works across local and national systems to support partners in addressing health threats (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and that options to improve training had been under consideration (The Thirlwall Inquiry legal team, May 2024).

Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally led by the provider trust.

In September 2024, the Department of Health and Social Care and NHS England reported that regulations require healthcare providers to publicise their complaints processes, which the Care Quality Commission can assess, and cited model procedures issued under the Parliamentary and Health Service Ombudsman's 2022 Complaint Standards (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team noted that a complaints guide for patients had been issued and a poster template made available (The Thirlwall Inquiry legal team, Feb 2026).

Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential litigation to agree to a stay of proceedings pending the outcome of the complaint, but the duties of the system to respond to complaints should be regarded as entirely separate from the considerations of litigation.

In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that regulations do not prohibit litigation and complaints on the same subject from proceeding in parallel, and that complainants are not prevented from pursuing a claim (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and that clarification had been published in March 2014 (The Thirlwall Inquiry legal team, May 2024).

Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation.

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England reported that work was ongoing, pointing to secondary care patient experience surveys, the Friends and Family Test, and provider Patient Advice and Liaison Services (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation, recording earlier commitments regarding ward signage on complaints, a complaints campaign, and Care Quality Commission inspection checks (The Thirlwall Inquiry legal team, May 2024).

Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as a formal complaint, whether or not the informant has indicated a desire to have the matter dealt with as such.

The Department of Health and Social Care and NHS England reported in February 2026 that collaborative complaint standards define a complaint as an expression of dissatisfaction requiring a response, and that clinical concerns link to patient safety incident frameworks (DHSC and NHS England, Feb 2026). They added that patients and families can share concerns about unsafe care using an online form following an autumn 2023 discovery phase (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and committed to handling concerns and complaints in accordance with individual needs (The Thirlwall Inquiry legal team, May 2024).

The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.

DHSC and NHS England stated in February 2026 that the recommendation was completed, referring to action regarding the Parliamentary and Health Service Ombudsman NHS Complaint Standards (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team noted that following universal expectations published in November 2014, the ombudsman publishes NHS Complaint Standards with a summary of expectations, a model complaint handling procedure and detailed guidance (The Thirlwall Inquiry legal team, Feb 2026).

Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that this recommendation was superseded, citing statutory duties to investigate complaints alongside guidance under the Patient Safety Incident Response Framework to combine complaint and safety incident investigations where possible (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had pointed to NHS England's Serious Incident Framework published in March 2015 (The Thirlwall Inquiry legal team, May 2024).

Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support.

The Department of Health and Social Care and NHS England stated in September 2024, in commentary published in February 2026, that complainants requiring support should have access to provider-operated Patient Advice and Liaison Services, alongside assistance from the Independent NHS Complaints Advocacy Service and local Healthwatch (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation as best practice and had proposed reviewing advocacy and support arrangements (The Thirlwall Inquiry legal team, May 2024).

Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.

In September 2024, the Department of Health and Social Care and NHS England reported that the measure was partially implemented, stating that Local Healthwatch can obtain annual complaints information on request under statutory regulations, supplemented by local reporting arrangements, Learn From Patient Safety Events, and published national complaints statistics (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation and committed to incorporating complaints data into existing electronic collection systems (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission had moved away from mandated provider information returns outside adult social care, but requests evidence on complaints during ongoing assessments and can compel providers to share details (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and had previously pointed to Quality Surveillance Groups sharing intelligence on care quality (The Thirlwall Inquiry legal team, May 2024).

GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so that they do not merely treat each case on its individual merits. They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers in order to make patients' choice reality. A GP's duty to a patient does not end on referral to hospital, but is a continuing relationship. They will need to take this continuing partnership with their patients seriously if they are to be successful commissioners.

In September 2024, the Department of Health and Social Care and NHS England reported that GP practices work together in primary care networks and highlighted that national guidance on system quality groups was issued in January 2022 to support quality improvement (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation and cited earlier measures, including a July 2014 commissioning for quality framework and the use of quality surveillance groups to share intelligence (The Thirlwall Inquiry legal team, Feb 2026).

In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with enhanced standards or development towards higher standards. They can incentivise such improvements either financially or by other means designed to enhance the reputation and standing of clinicians and the organisations for which they work.

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England noted that the recommendation remained in progress, referring to their response on a preceding recommendation (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation and planned to use contractual indicators and dedicated funding to encourage higher standards (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in February 2015 that quality frameworks and incentive schemes had been established to reward service improvements under provider contracts (Department of Health, Feb 2015).

The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as new clinical commissioning groups are formed, and guidance for commissioners on what they should expect to see in any organisational transitions amongst their providers.

In February 2026, the Department of Health and Social Care and NHS England reported that guidance and due diligence checklists had been used during transitions to integrated care boards to ensure corporate memory was preserved (DHSC and NHS England, Feb 2026).

The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny of its providers' services, based on sound commissioning contracts, while ensuring providers remain responsible and accountable for the services they provide.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that all NHS commissioners have teams to monitor contracted service delivery, clinical outcomes, and quality, and that the NHS Standard Contract is mandated to provide a sound basis for local contracts (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team reported that the recommendation had been accepted and noted earlier government updates regarding the contract and commissioning support services (The Thirlwall Inquiry legal team, May 2024).

Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including specialist clinical advice and procurement expertise. When groups are too small to acquire such support, they should collaborate with others to do so.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that Integrated Care Boards can enter joint working arrangements and obtain specialist commissioning support from four Commissioning Support Units (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and had previously reported developing commissioning support services and a Lead Provider Framework agreement (The Thirlwall Inquiry legal team, May 2024).

In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental safety and quality standards are maintained. This requires close engagement with patients, past, present and potential, to ensure that their expectations and concerns are addressed.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was partially implemented and ongoing, directing readers to their response regarding the Commissioning for Quality and Innovation scheme (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had pointed to guidance published in July 2014 to help commissioners assure service quality and safety (The Thirlwall Inquiry legal team, May 2024).

Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to consult clinicians both from potential providers and elsewhere, and to be willing to receive proposals, but in the end it is the commissioner whose decision must prevail.

The Department of Health and Social Care and NHS England stated in February 2026 that Integrated Care Boards are responsible for planning health services for their local population, managing the NHS budget, and agreeing joint five-year plans with local providers (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation was accepted by the government, which had highlighted mechanisms for clinicians to offer advice and proposals to commissioners (The Thirlwall Inquiry legal team, May 2024).

Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken on behalf of consortia of commissioning groups to provide the negotiating weight necessary to achieve a negotiating balance of power with providers.

In February 2026, DHSC and NHS England stated that the recommendation had been superseded, explaining that Integrated Care Systems had been established by the Health and Care Act 2022 and Integrated Care Boards had replaced clinical commissioning groups (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation and recorded earlier progress towards introducing collaborative commissioning arrangements (The Thirlwall Inquiry legal team, May 2024).

Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such monitoring may include requiring quality information generated by the provider. Commissioners must also have the capacity to undertake their own (or independent) audits, inspections, and investigations. These should, where appropriate, include investigation of individual cases and reviews of groups of cases. The possession of accurate, relevant, and useable information from which the safety and quality of a service can be ascertained is the vital key to effective commissioning, as it is to effective regulation. Monitoring needs to embrace both compliance with the fundamental standards and with any enhanced standards adopted. In the case of the latter, they will be the only source of monitoring, leaving the healthcare regulator to focus on fundamental standards.

The Department of Health and Social Care and NHS England stated in September 2024 that the NHS Standard Contract allows commissioners to require performance audits and inspect provider premises, while the NHS Oversight Framework uses metrics to prompt further investigation (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team reviewed earlier updates on commissioning support frameworks and recorded the recommendation without assessing implementation as complete (The Thirlwall Inquiry legal team, May 2024).

Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that local authorities commission complaint advocacy services, with additional support provided by local Healthwatch services (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and that local authorities were given responsibility for commissioning NHS complaints advocacy under the Health and Social Care Act 2012 (The Thirlwall Inquiry legal team, May 2024).

Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of technical support. Effective local commissioning can only work with effective local monitoring, and that cannot be done without knowledgeable and skilled local personnel engaging with an informed public.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England marked the recommendation as superseded, stating that services are commissioned by integrated care boards and NHS England under the NHS Oversight Framework (DHSC and NHS England, Feb 2026). Prior to that, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and recorded the accountability mechanisms for clinical commissioning groups set out in earlier responses (The Thirlwall Inquiry legal team, May 2024).

Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that work was ongoing, stating that the NHS Oversight Framework and 2022 system quality group guidance govern interventions and maintain service continuity when providers face difficulties (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented, pointing to earlier government reports on provider failure planning (The Thirlwall Inquiry legal team, May 2024).

The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such an organisation must require convincing evidence to be available before accepting that such standards are being complied with.

The Department of Health and Social Care and NHS England stated in September 2024 that fundamental standards were in place with Care Quality Commission enforcement powers mapped to Quality Statements within the Single Assessment Framework, though the regulator does not enforce enhanced standards (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had historically relied on provider licensing, registration, and inspection regimes to provide assurance (The Thirlwall Inquiry legal team, May 2024).

Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant information with the relevant regulator, including information about its judgement as to the safety of patients of the healthcare provider.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented on an ongoing basis, pointing to information on the NHS Oversight Framework and System Quality Groups (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government had previously relied on Quality Surveillance Groups, risk summits, and bilateral agreements to provide the framework for sharing safety information with regulators (The Thirlwall Inquiry legal team, May 2024).

For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the reality.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England referred to responses on quality groups, incident reporting, and the NHS Oversight Framework (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted, citing government statements on provider accountability and information flows under the NHS Standard Contract (The Thirlwall Inquiry legal team, May 2024).

Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression to poor performance can be identified and accepted as needing to be fixed.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the NHS Oversight Framework incorporates metrics aligned with quality of care, access, and outcomes, alongside coordinated data collections on quality and patient safety (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team reviewed the recommendation, noting earlier government updates from 2014 and 2015 regarding the publication of hospital performance statistics and safety indicators (The Thirlwall Inquiry legal team, May 2024).

The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of these through its regional offices, if appropriate.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded implementation as ongoing, stating, "Please see response to recommendation 143" (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted earlier updates regarding the NHS Outcomes Framework and specialty reporting (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in February 2015 that an outcomes indicator set for clinical commissioning groups was expanding annually and that consultant-level outcomes data was scheduled to be published before 2020 (Department of Health, Feb 2015).

Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented, noting that guidance on local authority scrutiny had been updated in January 2024 to establish five best-practice principles for collaborative working (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had previously issued health scrutiny guidance to local authorities in June 2014 (The Thirlwall Inquiry legal team, May 2024).

The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that Healthwatch continues to offer a range of training and resources for local Healthwatch staff and volunteers (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team reviewed implementation, noting that the government had accepted the recommendation and that training, support, and access to expert advice were being made available (The Thirlwall Inquiry legal team, May 2024).

Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.

In commentary of September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated: "Please see response to recommendation 147." (DHSC and NHS England, Feb 2026) In that February 2026 review, the Thirlwall Inquiry legal team noted that the government had reported issuing health scrutiny guidance in June 2014 alongside data transparency programmes (The Thirlwall Inquiry legal team, Feb 2026). The department had earlier reported in February 2015 that it jointly commissioned a support programme for local authorities for 2014/15 (Department of Health, Feb 2015).

Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, must be required to inform the relevant training regulator of those concerns.

In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that implementation was ongoing, noting that Health Education England merged with NHS England in 2023 and that an Education Quality Framework was refreshed in 2024 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that information-sharing protocols had been agreed between the Care Quality Commission, the General Medical Council, and the Nursing and Midwifery Council to share concerns about training (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of healthcare organisations which provide regulated training.

In commentary provided in September 2024 and published in February 2026, DHSC and NHS England reported that Monitor and Health Education England now form part of the latter organisation, referring to separate responses regarding regulator partnerships and the training provider quality framework (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that the Care Quality Commission had agreed joint operational protocols with the General Medical Council and the Nursing and Midwifery Council, as well as a September 2014 memorandum of understanding with the Healthcare Professions Council (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles: The Postgraduate Dean should be responsible for managing the process at the level of the Local Educational Training Board, as part of overall deanery functions. The Royal Colleges should be enlisted to support such visits and to provide the relevant specialist expertise where required. There should be lay or patient representation on visits to ensure that patient interests are maintained as the priority. Such visits should be informed by all other sources of information and, if relevant, coordinated with the work of the Care Quality Commission and other forms of review. The Department of Health should provide appropriate resources to ensure that an effective programme of monitoring training by visits can be carried out. All healthcare organisations must be required to release healthcare professionals to support the visits programme. It should also be recognised that the benefits in professional development and dissemination of good practice are of significant value.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that the General Medical Council updated its quality assurance approach in 2018, enhancing the role of Medical Royal Colleges and using lay associates on visits (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that while an October 2014 update report accepted one part of the recommendation, it was unclear whether the other recommendations were accepted (The Thirlwall Inquiry legal team, May 2024).

The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded progress as ongoing, stating that actions in the NHS Long Term Workforce Plan support their commitment to improving the quality of healthcare education and training (DHSC and NHS England, Feb 2026). Prior to this, the Thirlwall Inquiry legal team noted in May 2024 that the General Medical Council published a new standards framework in July 2015, which came into effect in January 2016 (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports should include a description of all relevant activity and findings and not be limited to exceptional matters of perceived non-compliance with standards. Without a compelling and recorded reason, no professional in a training organisation interviewed by a regulator in the course of an investigation should be bound by a requirement of confidentiality not to report the existence of an investigation, and the concerns raised by or to the investigation with his own organisation.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that deaneries routinely report to the General Medical Council through its quality reporting system, with serious concerns published on its website, while it is reviewing the best methods for sharing good practice (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and recorded previous progress updates from 2014 and 2015 (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, and should generally place the highest priority on the safety of patients.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that the General Medical Council had embedded patient safety into its 2016 standards and was beginning work to review its education framework (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that the council's revised standards took effect in January 2016, requiring organisations to seek and respond to feedback from learners and educators on patient safety and care (The Thirlwall Inquiry legal team, May 2024).

Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the survey and routinely share information obtained with healthcare regulators.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the General Medical Council routinely shares National Training Survey data and monthly monitoring summaries with the Care Quality Commission, as well as urgent safety risks through the Emerging Concerns Protocol (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the survey had been amended to explain how trainee concerns would be addressed to help providers identify patient safety problems (The Thirlwall Inquiry legal team, May 2024).

Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and ongoing, reporting that trainees can access Freedom to Speak Up Guardians and that awareness of speaking up processes is monitored through the annual National Education and Training Survey (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the General Medical Council had published training standards requiring organisations to foster a culture where learners can raise concerns openly and safely without fear of adverse consequences (The Thirlwall Inquiry legal team, May 2024).

Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used. Visits to, and observation of, the actual training environment would enable visitors to detect poor practice from which both patients and trainees should be sheltered. The opportunity can be taken to share and disseminate good practice with trainers and management. Visits of this nature will encourage the transparency that is so vital to the preservation of minimum standards.

In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the General Medical Council integrates training visits into its quality assurance processes, conducting visits alongside annual provider self-assessments and attending local visits for cases under enhanced monitoring (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the regulator had begun publishing validated education concerns, added evidence registers to visit reports, set a five-year visit schedule, and decided to pilot inspection teams observing clinical teaching environments (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first priority the safety of patients. It should also ensure that providers of clinical placements are unable to take on students or trainees in areas which do not comply with fundamental patient safety and quality standards. Regulators and deaneries should exercise their own independent judgement as to whether such standards have been achieved and if at any stage concerns relating to patient safety are raised to the, must take appropriate action to ensure these concerns are properly addressed.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the General Medical Council has improved its quality assurance processes, introducing enhanced monitoring that allows it to place conditions on or withdraw approval from training institutions with persistent safety concerns (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the regulator had published new education standards in 2015 stating that "Patient safety is at the core of these standards" (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure patient safety in the course of training.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, noting that the General Medical Council published standards for medical education and training in July 2015 (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team reported in May 2024 that these standards, effective from January 2016, required healthcare organisations to maintain enough suitably qualified staff for patient safety and appropriate clinical supervision (The Thirlwall Inquiry legal team, May 2024).

Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that Health Education England merged into the latter in April 2023, and that the combined body has a Chief Workforce, Training and Education Officer supported by a Director of Education and Training (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that there was "no mention in the Government’s response of a lay patient representative" (The Thirlwall Inquiry legal team, May 2024).

All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that Local Education and Training Boards had been superseded by Regional People Boards, but that NHS England regions have postgraduate dean roles in place (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and had previously confirmed that all training boards had qualified postgraduate deans (The Thirlwall Inquiry legal team, May 2024).

The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required for a registered medical practitioner to assume professional responsibility for medical treatment of an English-speaking patient.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented, stating that professional regulators, including the NMC and HCPC, have requirements in place to ensure English proficiency (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that 2014 legal amendments had introduced language checks for European doctors where concerns arose, but noted that it was unclear what action had been taken in respect of other healthcare workers (The Thirlwall Inquiry legal team, May 2024).

Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open and truthful.

The Inquiry asked healthcare organisations and their staff to be honest, open, and truthful. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and National Health Service (NHS) England stated that the values set out in the NHS Constitution are embodied in the NHS Patient Safety Strategy and noted the statutory duty of candour introduced in 2014 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation, pointing to professional codes of practice, Care Quality Commission inspection ratings, and the statutory duty of candour (The Thirlwall Inquiry legal team, May 2024).

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be informed of the incident, given full disclosure of the surrounding circumstances and be offered an appropriate level of support, whether or not the patient or representative has asked for this information.

In commentary published in February 2026, the Department of Health and Social Care and NHS England described progress as ongoing, referring to their responses regarding the statutory duty of candour and safety incident frameworks (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that 2014 regulations had established a duty of candour on health service bodies as a requirement for registration with the Care Quality Commission (The Thirlwall Inquiry legal team, May 2024).

Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative).

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that implementation was ongoing, noting that statutory regulators require health and care professionals to be open and honest about harm, with joint guidance updated in March 2022 (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation and that regulators had issued joint duty of candour guidance in 2015 (The Thirlwall Inquiry legal team, May 2024).

Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.

In February 2026, the Department of Health and Social Care and NHS England referred progress on this recommendation to their response on the statutory duty of candour (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the government had created an offence in section 92 of the Care Act 2014 for supplying, publishing or making available false or misleading information, and noted that the NHS Standard Contract included a requirement of good faith (The Thirlwall Inquiry legal team, May 2024).

Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.

In February 2026, the Department of Health and Social Care and NHS England stated that implementation was ongoing, pointing to the statutory duty of candour and NHS Standard Contract requirements to ensure submissions are not misleading (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation was implemented, noting that section 92 of the Care Act 2014 created an offence of making available false or misleading information (The Thirlwall Inquiry legal team, May 2024).

"Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care.

The Inquiry called for gagging clauses to be prohibited across healthcare organisations, regulators, and commissioners. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and National Health Service (NHS) England described guidance for employers stating that settlement agreements "should only be used in exceptional circumstances", but regulators and commissioners are not mentioned in the sources (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and required compromise agreements to explicitly permit disclosures in the public interest (The Thirlwall Inquiry legal team, May 2024).

Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the Being Open guidance had been superseded by the organisational Duty of Candour and newer Patient Safety Incident Response Framework guidance (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation and had sought to ensure duty of candour regulations were congruent with the Being Open framework (The Thirlwall Inquiry legal team, May 2024).

There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory obligation on the organisation to provide it.

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented, referring to action taken regarding the statutory duty of candour and the fit and proper person framework (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the government had enacted an offence under section 92 of the Care Act 2014 covering false or misleading information supplied by healthcare providers and their directors (The Thirlwall Inquiry legal team, May 2024).

Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by monitoring undertaken by commissioners and others.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission had implemented the recommendation and that enforcement remained an ongoing piece of work, alongside a departmental review of the duty of candour held in early 2024 (DHSC and NHS England, Feb 2026). Prior to that, in May 2024, the Thirlwall Inquiry legal team noted that the commission had been granted statutory enforcement powers, including warning and requirement notices, the imposition of conditions, and criminal prosecutions (The Thirlwall Inquiry legal team, May 2024).

There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: Selection of recruits to the profession who evidence the: Possession of the appropriate values, attitudes and behaviours; Ability and motivation to enable them to put the welfare of others above their own interests; Drive to maintain, develop and improve their own standards and abilities; Intellectual achievements to enable them to acquire through training the necessary technical skills; Training and experience in delivery of compassionate care; Leadership which constantly reinforces values and standards of compassionate care; Involvement in, and responsibility for, the planning and delivery of compassionate care; Constant support and incentivisation which values nurses and the work they do through: Recognition of achievement; Regular, comprehensive feedback on performance and concerns; Encouraging them to report concerns and to give priority to patient well-being.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England reported that progress was ongoing, stating that the Nursing and Midwifery Council had overhauled its regulatory framework and published new pre-registration education standards in 2018 and 2019 that emphasise compassionate care (DHSC and NHS England, Feb 2026). They also noted that three-yearly revalidation had been introduced to encourage reflection on professional standards (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that a 2015 evaluation had found earlier education standards broadly effective while identifying areas for future development (The Thirlwall Inquiry legal team, May 2024).

Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.

The Department of Health and Social Care and NHS England reported in February 2026 that the recommendation was partially implemented and closed, stating that the Nursing and Midwifery Council viewed its standards requiring 50 percent practice learning as meeting the recommendation, though the council had committed to reviewing those requirements further (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that an earlier evaluation had judged the council's education standards broadly effective while identifying points for future revision (The Thirlwall Inquiry legal team, May 2024).

There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct care of patients, ideally including the elderly, and involve hands-on physical care. Satisfactory completion of this direct care experience should be a pre-condition to continuation in nurse training. Supervised work of this type as a healthcare support worker should be allowed to count as an equivalent. An alternative would be to require candidates for qualification for registration to undertake a minimum period of work in an approved healthcare support worker post involving the delivery of such care.

The Department of Health and Social Care and NHS England reported in September 2024 that implementation was ongoing, explaining that updated 2023 Nursing and Midwifery Council standards maintained the requirement that 50 percent of degree hours be spent in practice learning (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that while earlier government pilot programmes had run through 2015, the regulator had not considered that requiring candidates to undertake a healthcare support role would advance patient safety (The Thirlwall Inquiry legal team, May 2024).

Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the NHS operates a values-based recruitment approach to attract students, trainees and employees "on the basis that their individual values and behaviours align with the values of the NHS constitution" (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and previously cited the introduction of values testing for NHS-funded training posts and employer mapping tools (The Thirlwall Inquiry legal team, May 2024).

The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and, in particular, to the priority to be accorded to dignity and respect, and their acquisition of leadership skills.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that the recommendation had been superseded, noting that the Knowledge and Skills Framework is no longer updated by NHS Employers and that an improved national appraisal framework was scheduled to launch in 2025/26 (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the framework was absent from a 2015 government update and that "it is unclear whether any review of the Framework was undertaken" (The Thirlwall Inquiry legal team, May 2024).

Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such as the "cultural barometer".

The Inquiry recommended incentivising healthcare providers to measure the cultural health of nursing workplaces. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the National Health Service (NHS) staff survey and NHS People Pulse provide a standardised framework to measure employee experience, with results publicly available (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that a guide on implementing the culture barometer was published in April 2017, but noted that it was unclear what incentives, if any, were implemented (The Thirlwall Inquiry legal team, May 2024).

Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on duty should, whenever possible, be present at every interaction between a doctor and an allocated patient.

In February 2026, the Department of Health and Social Care and NHS England reported, in commentary submitted in September 2024, that the named nurse model of care is used across the NHS to ensure safe and effective inpatient care (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that although the government accepted the recommendation and professional guidance was published in 2014, having a named nurse was not made a mandatory requirement (The Thirlwall Inquiry legal team, May 2024).

The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions between two bodies rather than behind internal "Chinese walls".

In February 2026, the Department of Health and Social Care and NHS England reported that while the Royal College of Nursing had sought to delineate its roles, it continues to act as both a trade union and a professional body (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that although the government accepted the recommendation, the college had decided in July 2013 against splitting its functions (The Thirlwall Inquiry legal team, May 2024). The department had previously affirmed in November 2013 that the college viewed its dual responsibilities as complementary and chose to remain a single entity (Department of Health response, Nov 2013).

Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions must regularly review the adequacy of the arrangements in this regard.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England noted that part 4, section 25 of the NHS Terms and Conditions Handbook relates to time off and facilities for trade union representatives (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation as a matter for local employers and unions, endorsed by the Royal College of Nursing, UNISON, and NHS Employees (The Thirlwall Inquiry legal team, May 2024).

A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of coordinating the leadership of the nursing profession.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the Chief Nursing Officer for England provides clinical and professional leadership across health and social care, supported by regional and Integrated Care Board chief nurses (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and that the government had cited the creation of the Federation of Nurse Leaders to coordinate nursing leadership (The Thirlwall Inquiry legal team, May 2024).

The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a recognised leading representative of the nursing profession as a whole, able and empowered to give independent professional advice to the Government on nursing issues of equivalent authority to that provided by the Chief Medical Officer.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the role of Chief Nursing Officer was "now well-embedded within the national landscape", with the post holder reporting directly to the service's Chief Executive, advising the Secretary of State, and undergoing regular appraisal (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that while the government accepted the recommendation with a commitment to ongoing review, it provided no update in its February 2015 report (The Thirlwall Inquiry legal team, May 2024).

There should be a national code of conduct for healthcare support workers.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, highlighting the 2019 Healthcare Support Worker programme and the 2023 NHS Long Term Workforce Plan (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that a national code of conduct for healthcare support workers and adult social workers was published in March 2013 (The Thirlwall Inquiry legal team, May 2024).

There should be a common set of national standards for the education and training of healthcare support workers.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that the Care Quality Commission continues to support and expect the Care Certificate to be used across health and social care (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the Care Certificate had been introduced in April 2015 to establish fundamental skills, values, and behaviours for new healthcare assistants and social care support workers, replacing earlier minimum training standards (The Thirlwall Inquiry legal team, May 2024).

A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership and management as a profession; administer an accreditation scheme to enhance eligibility for consideration for such roles; promote and research best leadership practice in healthcare.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that work remained ongoing, with plans to introduce a nationally consistent training delivery model once a curriculum is finalised, after which leadership and management offers will be refreshed in line with that curriculum (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.

The Inquiry recommended an enforceable code of ethics and conduct for senior healthcare leaders. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that a leadership competency framework for board members was published in February 2024, alongside ongoing co-development of a wider leadership framework and code of practice (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry recorded that the NHS Leadership and Management Framework Code was published in July 2026 (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026). The inquiry chair concluded that an omission undermined the document's credibility and recommended an urgent review of the code (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).

The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining the service to be delivered as a safe and effective service.

In February 2026, the Department of Health and Social Care and NHS England reported that the first competency of the Leadership Competency Framework focuses on safe and effective services, and noted that the Patient Safety Incident Response Framework is a contractual requirement under the NHS Standard Contract (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and that a healthcare leadership model comprised of nine leadership dimensions had been published in November 2013 (The Thirlwall Inquiry legal team, May 2024).

Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a fair and proportionate procedure, with the effect of disqualifying them from holding such positions in future.

In September 2024, the Department of Health and Social Care and NHS England reported that implementation was ongoing, noting that the department was exploring options to introduce professional standards for NHS managers and bring them into regulation (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation for the Care Quality Commission to determine how the test would be applied in practice (The Thirlwall Inquiry legal team, May 2024). The department had reported in February 2015 that regulations introducing the fit and proper person test took effect for NHS bodies in November 2014, empowering the commission to require the removal of directors who fail it (Department of Health, Feb 2015).

Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards of health service bodies which are not foundation trusts, of equivalent rigour to that applied to foundation trusts.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the Care Quality Commission assesses corporate governance through its Well-led Framework, supported by provider licence conditions and a 2023 trust code of governance (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had tasked the commission alongside the NHS Trust Development Authority with overseeing governance standards across non-foundation trusts (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.

DHSC and NHS England reported in September 2024 that the General Medical Council publishes information on how complaints and referrals are managed, which includes explaining appropriate channels for raising concerns and signposting complainants to the appropriate regulator (DHSC and NHS England, Feb 2026). In an assessment published in February 2026, the Thirlwall Inquiry legal team noted that the recommendation had been accepted but found that it remained unclear whether any clear policy was developed (The Thirlwall Inquiry legal team, Feb 2026).

Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same effect.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented, noting that action had been taken in response to it (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the General Medical Council had produced information sharing guidance for employers and had entered into an information sharing agreement with the Academy of Medical Royal Colleges in September 2016 (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual concerns. Such reviews could be jointly commissioned with the Care Quality Commission in appropriate cases.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the General Medical Council works alongside other regulators through the Joint Strategic Oversight Group to share intelligence and develop aligned approaches (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and that the council had previously undertaken to explore joint ownership of generic issues (The Thirlwall Inquiry legal team, May 2024).

It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is still found by other reviews to be wanting. It is imperative in the public interest that this is remedied urgently. Without doing so, there is a danger that the regulatory gap between the Nursing and Midwifery Council and the Care Quality Commission will widen rather than narrow.

In September 2024 commentary, the Department of Health and Social Care and NHS England stated that the recommendation was partially implemented, noting that while the Nursing and Midwifery Council had agreed a £30 million fitness to practise improvement plan, further action remained outstanding to address findings from a July 2024 independent review into culture, performance, and safeguarding (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation, recording earlier legislative amendments and case backlog clearances (The Thirlwall Inquiry legal team, May 2024).

It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional protection to the public. It is essential that the Nursing and Midwifery Council has the resources and the administrative and leadership skills to ensure that this does not detract from its existing core function of regulating fitness to practise of registered nurses.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the nursing revalidation process was introduced in April 2016 (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded in its review of previous inquiries that the recommendation had been accepted by the government and that the nursing revalidation process was introduced in April 2016 (The Thirlwall Inquiry legal team, May 2024).

The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. All patients should be informed, by those providing treatment or care, of the existence and role of the Nursing and Midwifery Council, together with contact details. The Nursing and Midwifery Council itself needs to undertake more by way of public promotion of its functions.

In February 2026, the Department of Health and Social Care and NHS England reported, in commentary from September 2024, that the Nursing and Midwifery Council had taken steps to raise its profile, including launching a dedicated referral helpline in 2023, establishing a Public Voice Forum, and researching audience perceptions (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and reviewed earlier actions, including the council's website relaunch, engagement forums, and guidance leaflets on raising concerns (The Thirlwall Inquiry legal team, May 2024).

It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. This may require a review of employment disciplinary procedures, to make it clear that the employer is entitled to proceed even if there are pending Nursing and Midwifery Council proceedings.

The Department of Health and Social Care and NHS England reported in February 2026 that the Nursing and Midwifery Council had introduced a Fitness to Practise Strategy in 2018 promoting a local-first approach, under which "employers should act first to deal with concerns" unless immediate regulatory action is needed, supported by detailed employer guidance (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and that the council had planned to review its guidance on fitness to practise processes (The Thirlwall Inquiry legal team, May 2024).

The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will have to be engaged in filling this gap.

The Department of Health and Social Care and NHS England reported in February 2026 that the recommendation was implemented, explaining that the Nursing and Midwifery Council introduced an Employer Link Service in 2016 that now employs 13 regulation advisers to support employers and directors of nursing (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that it was unclear how earlier plans for regional liaison advisers had been taken forward following a 2015 update (The Thirlwall Inquiry legal team, May 2024).

While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware at the point of service provision of their existence, their role and their contact details.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as in progress, stating that action taken by both regulators had been noted (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team reported in May 2024 that the General Medical Council had rolled out its Patient Information Service across the UK to improve communication with complainants, while the Nursing and Midwifery Council had produced two public information leaflets on raising concerns (The Thirlwall Inquiry legal team, May 2024).

Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to minimise the time taken to resolve issues and maximise the protection afforded to the public.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England referred to their response on the Joint Strategic Oversight Group for details on joint working (DHSC and NHS England, Feb 2026). In its review published in February 2026, the Thirlwall Inquiry legal team noted that the General Medical Council had developed an operational protocol with the Care Quality Commission, and that the Nursing and Midwifery Council had renewed its memorandum of understanding supported by a joint working protocol (The Thirlwall Inquiry legal team, Feb 2026).

Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who is in overall charge of a patient's care.

The Department of Health and Social Care and NHS England reported in February 2026 that regulations require providers of primary medical services to ensure each registered patient has a named accountable GP, citing 2014 guidance from the Academy of Medical Royal Colleges that care during a hospital stay should be coordinated by an individual named clinician (DHSC and NHS England, Feb 2026). Also in February 2026, the Thirlwall Inquiry legal team noted that the government accepted the recommendation and had recorded in 2015 that more than two thirds of trusts had implemented the "Name Above the Bed" or a similar initiative (The Thirlwall Inquiry legal team, Feb 2026).

There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance staff, and catering staff also needs to be recognised and valued.

In February 2026, the Department of Health and Social Care and NHS England reported that the NHS Long Term workforce plan focuses on optimising multidisciplinary teams, and that the Care Quality Commission assesses multidisciplinary team working under its Single Assessment Framework (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation and had asked NHS Employers to collate resources supporting team development (The Thirlwall Inquiry legal team, May 2024).

Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff need to be enabled to interact constructively, in a helpful and friendly fashion, with patients and visitors. Where possible, wards should have areas where more mobile patients and their visitors can meet in relative privacy and comfort without disturbing other patients. The NHS should develop a greater willingness to communicate by email with relatives. The currently common practice of summary discharge letters followed up some time later with more substantive ones should be reconsidered. Information about an older patient's condition, progress and care and discharge plans should be available and shared with that patient and, where appropriate, those close to them, who must be included in the therapeutic partnership to which all patients are entitled.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported implementation as ongoing, pointing to published guidance on shared decision-making, National Quality Board staffing expectations, and NHS Standard Contract workforce requirements (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted previous government commitments on values-based recruitment and hospital facilities but did not record the recommendation as fully implemented (The Thirlwall Inquiry legal team, May 2024).

The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time without absolute assurance that a patient in need of care will receive it on arrival at the planned destination. Discharge areas in hospital need to be properly staffed and provide continued care to the patient.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the August 2020 Hospital Discharge Service policy and operating model details discharge requirements across care providers to ensure patients are discharged safely and appropriately (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had pointed to earlier discharge planning guidance and fundamental care standards (The Thirlwall Inquiry legal team, May 2024).

All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that infection control guidance for healthcare staff was updated in 2024, including a national practice manual and workwear policies to support hand hygiene (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation (The Thirlwall Inquiry legal team, May 2024). Earlier, in February 2015, the department reported that new Care Quality Commission fundamental standards covering cleanliness and safety would take effect that April (Department of Health, Feb 2015).

The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.

In February 2026, the Department of Health and Social Care and NHS England stated that implementation was ongoing, noting that national standards for healthcare food and drink are published, statutory regulations require service users' nutritional needs to be met, and care guidance is provided (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation alongside earlier measures, including pilot funding to reduce malnutrition and guidance encouraging protected mealtimes (The Thirlwall Inquiry legal team, May 2024).

In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. This is particularly the case when patients are moved from one ward to another, or they are returned to the ward after treatment.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation had been superseded, noting that it predated updated regulatory standards, advice from NICE, and 2018 guidance on transfer of care (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had originally accepted the recommendation and had placed responsibility on hospital pharmacy teams to monitor and audit medication safety systems (The Thirlwall Inquiry legal team, May 2024).

The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form enabling progress to be monitored and interpreted. If this cannot be done, there needs to be a system whereby ward leaders and named nurses are responsible for ensuring that the observations are carried out and recorded.

The Inquiry recommended that healthcare providers record routine ward observations automatically and electronically. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that most trusts have electronic patient record (EPR) systems bringing together patient information, though automatic recording of ward observations was not mentioned (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that the government accepted the recommendation and had pointed to the Nursing Technology Fund (The Thirlwall Inquiry legal team, May 2024). In February 2015, the department reported that the first round of that fund awarded funding to 74 trusts, with a quarter of projects involving vital signs monitoring solutions (Department of Health, Feb 2015).

There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible, the summary care record should be made accessible in this way. Systems should be designed to include prompts and defaults where these will contribute to safe and effective care, and to accurate recording of information on first entry. Systems should include a facility to alert supervisors where actions which might be expected have not occurred, or where likely inaccuracies have been entered. Systems should, where practicable and proportionate, be capable of collecting performance management and audit information automatically, appropriately anonymised direct from entries, to avoid unnecessary duplication of input. Systems must be designed by healthcare professionals in partnership with patient groups to secure maximum professional and patient engagement in ensuring accuracy, utility and relevance, both to the needs of the individual patients and collective professional, managerial and regulatory requirements. Systems must be capable of reflecting changing needs and local requirements over and above nationally required minimum standards.

In February 2026, the Department of Health and Social Care and NHS England reported that the NHS App launched in January 2019, that changes to the GP Contract gave patients the right to access their GP records online on request from April 2020, and that a Federated Data Platform had been developed to bring operational data together (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted the recommendation, summarising earlier government updates regarding data standards, electronic patient records, and the Summary Care Record (The Thirlwall Inquiry legal team, May 2024).

Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form to enable comparisons to be made between organisations, to include a minimum of prescribed information about their compliance with fundamental and other standards, their proposals for the rectification of any non-compliance and statistics on mortality and other outcomes. Quality accounts should be required to contain the observations of commissioners, overview and scrutiny committees, and Local Healthwatch.

In commentary submitted in September 2024, the Department of Health and Social Care and NHS England stated that eligible NHS healthcare providers are required by regulations to publish annual Quality Accounts, citing guidance on reporting clinical audit participation and related improvements (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team found that while regulations prescribe certain details, there was no reference to this including information about compliance with fundamental standards or proposals to rectify non-compliance (The Thirlwall Inquiry legal team, Feb 2026).

Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators.

In September 2024, the Department of Health and Social Care and NHS England stated that the measure was implemented, noting that regulations require quality accounts to be published annually and emailed to NHS England or the department, while providers are advised to share them with commissioners, local Healthwatch, and scrutiny committees (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that "it is unclear whether providers were required to provide quality accounts directly to systems regulators" (The Thirlwall Inquiry legal team, May 2024).

Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability of all statements in the accounts.

In September 2024, the Department of Health and Social Care and NHS England reported that external assurance over quality accounts is no longer mandatory following legislative changes, though guidance advises that healthcare providers may still choose to audit them to verify accuracy (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that national requirements to audit NHS quality accounts no longer appeared to be in place (The Thirlwall Inquiry legal team, May 2024).

It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.

The Department of Health and Social Care and NHS England reported in September 2024 that the Health and Social Care Information Centre had merged into NHS England, which serves as the statutory custodian for health and care data and publishes anonymisation guidance alongside dashboards and open datasets (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and that a code of practice on confidential information had been published in December 2014 (The Thirlwall Inquiry legal team, May 2024).

The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the public domain, as far as is consistent with maintaining any legitimate confidentiality of such information, together with appropriate explanations to enable the public to understand the limitations of this tool.

In September 2024, the Department of Health and Social Care and NHS England stated that the recommendation had been superseded, noting that the Care Quality Commission had phased in a new single assessment framework since November 2023 and publishes inspection reports online (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation and recounted previous updates on risk monitoring tools and published data packs (The Thirlwall Inquiry legal team, Feb 2026).

While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be consistency across the country in methods of access, and for the output to be published in a manner allowing fair and informed comparison between organisations.

In September 2024, the Department of Health and Social Care and NHS England reported that the Friends and Family Test gives patients and carers the opportunity to leave feedback across most health services, but noted that "the FFT is not intended to provide data that can be used to compare different organisations" (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the extent to which national consistency in feedback access had been achieved remained unclear (The Thirlwall Inquiry legal team, May 2024).

Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" as possible, even if later adjustments have to be made.

In commentary submitted in September 2024, the Department of Health and Social Care and NHS England reported that the Friends and Family Test functions as a continuous feedback tool with results published monthly, classifying implementation as ongoing (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team reviewed progress, noting earlier government initiatives to publish patient feedback monthly and develop digital feedback options through electronic records (The Thirlwall Inquiry legal team, May 2024).

A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their care.

The Inquiry recommended that healthcare providers proactively follow up with patients after discharge to gather feedback. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England cited their August 2020 hospital discharge guidance, describing patient leaflets and staff action cards, but did not mention post-discharge follow-up for feedback (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had left trusts to decide how to follow up with patients while the Care Quality Commission assessed complaints during inspections (The Thirlwall Inquiry legal team, May 2024).

The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.

In commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as superseded, referring to their response to recommendation 252 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had originally accepted the recommendation and that the Health and Social Care Information Centre kept its indicator methodologies under regular review (The Thirlwall Inquiry legal team, May 2024).

The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns of clinically related complaints.

In September 2024, the Department of Health and Social Care and NHS England reported that NHS Digital publishes data on written complaints across primary and secondary care in England, explaining that collections shifted from quarterly reporting between 2015-16 and 2021-22 to an annual basis from 2022-23 (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and that quarterly complaints data were being published (The Thirlwall Inquiry legal team, May 2024).

The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as superseded, referring to their response to an earlier recommendation (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and recounted its prior updates on high-level data analysis (The Thirlwall Inquiry legal team, May 2024). The department had reported in February 2015 that the Health and Social Care Information Centre was reviewing its publications strategy to produce more thematic reports, following its initial acceptance in November 2013 (Department of Health response, Nov 2013; Department of Health, Feb 2015).

All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against patient safety and minimum quality standards; Effective real-time information of the performance of each of their consultants and specialist teams in relation to mortality, morbidity, outcome and patient satisfaction. In doing so, they should have regard, in relation to each service, to best practice for information management of that service as evidenced by recommendations of the Information Centre, and recommendations of specialist organisations such as the medical Royal Colleges. The information derived from such systems should, to the extent practicable, be published and in any event made available in full to commissioners and regulators, on request, and with appropriate explanation, and to the extent that is relevant to individual patients, to assist in choice of treatment.

The Department of Health and Social Care and NHS England stated in September 2024 that implementation was in progress, pointing to the Federated Data Platform, the Consultant Outcomes Publication, and the National Consultant Information Programme portal for consultant-level data (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation to connect existing systems using national standards rather than imposing central requirements on local providers (The Thirlwall Inquiry legal team, May 2024).

It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.

In February 2026, the Department of Health and Social Care and NHS England reported that professional bodies require accurate records, 99 percent of trusts in England were enrolled in NCIP, and portal access across 14 surgical specialties was on track for April 2025 before expanding into non-surgical specialties (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that although the government accepted the recommendation, it had not set out its position on how such a professional duty was to be "envisaged or implanted" (The Thirlwall Inquiry legal team, May 2024).

In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.

The Department of Health and Social Care and NHS England stated in September 2024, in commentary published in February 2026, that the recommendation was implemented, noting that statistics on the effectiveness of treatments and interventions are published by NHS Digital and the National Institute for Health and Care Excellence (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented, reviewing past progress on publishing specialty and consultant-level outcome data (The Thirlwall Inquiry legal team, May 2024).

The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on the efficacy of treatment in that specialty, for publication and use in performance oversight, revalidation, and the promotion of patient knowledge and choice.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that patient choice had been incorporated into the NHS Long Term Plan, noting that standard contract terms require providers to publish acute referral services through a directory (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation and summarised earlier updates regarding consultant outcomes publications (The Thirlwall Inquiry legal team, May 2024). Previously, in February 2015, the department reported that consultant outcome data had been published for several specialties, with work remaining in progress to identify what further data could feasibly be collected (Department of Health, Feb 2015).

In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard to the views of patient groups and the public about the information needed by them.

The Department of Health and Social Care and NHS England reported in February 2026 that NHS England frequently conducts public consultations on key statistical reports, data released, and proposed changes to data collection methods to allow public feedback on how patient statistics are collected and used (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation and stated that NHS England would consider the role of service users in taking the programme forward (The Thirlwall Inquiry legal team, May 2024).

All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.

In commentary from September 2024, published in February 2026, DHSC and NHS England stated that patient outcome statistics are publicly available through various platforms, including NHS Digital's website, Care Quality Commission inspection reports, and their own public portals (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been accepted and that data was made available through the NHS Choices website in 2014 (The Thirlwall Inquiry legal team, May 2024).

Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.

The Inquiry called for healthcare providers to allocate resources to collect and forward data to central registries. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that resources have been allocated to support data collection, though forwarding data to central registries was not mentioned (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and expected commissioning bodies to fund provider data collection through overall contract budgets (The Thirlwall Inquiry legal team, May 2024).

The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.

In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and ongoing, reporting that the monthly Data Quality Maturity Index provides data submitters with "timely and transparent information" (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and committed to continuing local clinical record audits alongside developing a national data quality assurance framework (The Thirlwall Inquiry legal team, May 2024).

There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other outcome indicators. In particular, there could be benefit from consideration of the extent to which these statistics can be published in a form more readily useable by the public.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that patient outcome statistics are publicly available through various platforms, including its website, public portals, and Care Quality Commission inspection reports (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the UK Statistics Authority had reviewed patient outcome statistics in February 2014, leading the Secretary of State for Health to commission independent assessments for seven sets of statistics (The Thirlwall Inquiry legal team, May 2024).

To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should work towards establishing such status for them or any successor hospital mortality figures, and other patient outcome statistics, including reports showing provider-level detail.

The Inquiry asked the department to secure national statistics status for hospital mortality indicators. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the Summary Hospital-Level Mortality Indicator is published monthly as an Accredited Official Statistic, though other patient outcome statistics were not mentioned (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the indicator appeared to be designated as an official statistic (The Thirlwall Inquiry legal team, May 2024). In August 2016, the Office for Statistics Regulation confirmed the designation of the indicator as a National Statistic (Ed Humpherson, Aug 2016).

There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and Social Care Act 2012, it should be used as soon as practicable.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as partially implemented, stating that statutory powers facilitate accreditation and that bodies such as the Data Alliance Partnership Board assure information standards (DHSC and NHS England, Feb 2026). Prior to that, the Thirlwall Inquiry legal team found in May 2024 that it could not "find any evidence this was implemented" by either the Health and Social Care Information Centre or its successor, NHS Digital (The Thirlwall Inquiry legal team, May 2024).

There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness over any perceived material interest.

The Inquiry asked for guidance ensuring openness takes priority when disclosing information to coroners. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and National Health Service (NHS) England stated that medical examiners had been introduced under a statutory duty of candour and favoured openness with bereaved families, though guidance for trusts and legal advisers on disclosure to coroners was not described (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government accepted the recommendation but had not provided details about what guidance was given (The Thirlwall Inquiry legal team, May 2024). Earlier, in January 2016, Parliamentary Under-Secretary Ben Gummer reported that the 2015 NHS Serious Incident Framework provided advice on sharing information with coroners, patients, and families (Ben Gummer, Jan 2016).

Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.

The Inquiry called for enough independent medical examiners to be appointed and properly resourced. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the system had become statutory that month, all acute NHS trusts had established medical examiner offices, and trusts had been asked to ensure adequate workforce and support (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry reported that funding for medical examiners was no longer ring-fenced, with integrated care boards (ICBs) instead funded to provide the service (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).

National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.

In commentary from September 2024, published in February 2026, DHSC and NHS England stated that the recommendation had been implemented, explaining that guidance on completing the Medical Cause of Death Certificate is published by the department alongside the introduction of medical examiners (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation was accepted by the government and guidance was first published in September 2018 (The Thirlwall Inquiry legal team, May 2024).

It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or not referred to in the medical records.

DHSC and NHS England stated in September 2024 that medical examiners had been introduced with statutory access to relevant records, operating under 2024 regulations requiring independent scrutiny of causes of death and the referral of care concerns to clinical governance processes, the coroner, or police (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that primary legislation providing the statutory framework for the medical examiner system came into force in October 2023 (The Thirlwall Inquiry legal team, May 2024).

So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient's case or treatment.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation had been implemented, noting that hospital guidance places ultimate responsibility on the consultant in charge of care to ensure deaths are properly certified (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team also found that guidance gives the consultant in charge responsibility for ensuring deaths are properly certified (The Thirlwall Inquiry legal team, May 2024).

Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may have with the independent medical examiner.

In September 2024, the Department of Health and Social Care and NHS England stated that medical examiners had now been introduced, noting that a key function is to give bereaved families greater transparency and opportunities to raise concerns (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team found that earlier draft death certification regulations had not been implemented, though primary legislation establishing the framework for a statutory medical examiner system came into force in October 2023 (The Thirlwall Inquiry legal team, Feb 2026).

It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner least likely to cause additional and unnecessary distress.

The Inquiry recommended training for medical examiners and others who approach bereaved families. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England described training for medical examiners, stating that regulations require periodic training and that examiners must complete 24 core online modules before starting work and face-to-face training within six months (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that primary legislation establishing the statutory framework came into force in October 2023 (The Thirlwall Inquiry legal team, May 2024).

Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that Regulation 28 reports, previously known as Rule 43 reports, are shared with the Care Quality Commission where it is a named respondent or interested organisation, and are also assessed alongside other evidence to identify provider risks (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team noted that the Coroners' Society of England and Wales had agreed for coroners to provide the commission with copies of any report where concerns regarding care or treatment by a registered provider arise during an inquest (The Thirlwall Inquiry legal team, Feb 2026).

Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact with the patient's family.

The Department of Health and Social Care and NHS England reported in February 2026 that the Judicial College delivers a training programme for all coroners, annual training is provided for coroners’ officers, and the Chief Coroner provides detailed guidance to coroners on their legal duties, policy, and practice (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation, citing previous reports of mandatory and continuation training programmes for coroners (The Thirlwall Inquiry legal team, May 2024).

The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that action had been noted in response to it (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team found that the recommendation had been accepted and that the Ministry of Justice and the Chief Coroner had published guidance in July 2013 specifying details for assistant coroner appointments (The Thirlwall Inquiry legal team, Feb 2026).

The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a case.

In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that action taken in response had been noted (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the Chief Coroner had issued guidance on bias in September 2014 (The Thirlwall Inquiry legal team, May 2024).

Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted. Such assessments should cover at least the following issues: What is the precise issue or concern in respect of which change is necessary? Can the policy objective identified be achieved by modifications within the existing structure? How are the successful aspects of the existing system to be incorporated and continued in the new system? How are the existing skills which are relevant to the new system to be transferred to it? How is the existing corporate and individual knowledge base to be preserved, transferred and exploited? How is flexibility to meet new circumstances and to respond to experience built into the new system to avoid the need for further structural change? How are necessary functions to be performed effectively during any transitional period? What are the respective risks and benefits to service users and the public and, in particular, are there any risks to safety or welfare?

In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England stated that an impact assessment was undertaken for the Health and Care Act and maintained that major changes of policy and system structure should be carefully considered (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation (The Thirlwall Inquiry legal team, May 2024).

The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and healthcare professionals, a coherent, and easily accessible structure for the development and implementation of values, fundamental, enhanced and developmental standards as recommended in this report.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented on an ongoing basis, noting that core values are set through the NHS Constitution and fundamental standards have been enforced by the Care Quality Commission since 2015 (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team recorded that the government had previously accepted the recommendation and consulted on fundamental standards regulations alongside provider handbooks (The Thirlwall Inquiry legal team, May 2024).

The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety and well-being.

In September 2024, the Department of Health and Social Care and NHS England stated that implementation was ongoing, reporting that roles including the Chief Medical Officer, Chief Nursing Officer, and Chief Scientific Adviser ensure senior clinical and scientific advice is embedded in policy making (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had reported arrangements to ensure access to clinical advice (The Thirlwall Inquiry legal team, May 2024).

Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health could also be assisted in its work by involving patient/service user representatives through some form of consultative forum within the Department.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented, stating that senior civil servants were required to spend 20 days a year connecting with health and care organisations and that engagement with service users remained ongoing (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted previous government reporting that over 500 departmental staff had taken part in more than 2,000 connecting days during the programme's first year (The Thirlwall Inquiry legal team, May 2024).

The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level possible.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that, as of September 2024, measures in place to increase transparency around care deficiencies included the organizational duty of candour, the Patient Safety Incident Response Framework, and national clinical audits (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and highlighted its initial transparency measures (The Thirlwall Inquiry legal team, May 2024).