Mid Staffordshire NHS Foundation Trust Public Inquiry

All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment.

The Department of Health and Social Care and NHS England reported in September 2024 that no systematic arrangements had been put in place through contractual terms, although NHS terms and conditions require local appraisal policies to align with the NHS Constitution (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that it was unclear whether any amendments had been made to contracts of employment (The Thirlwall Inquiry legal team, May 2024).

The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the change was complete, explaining that the NHS Constitution references standards of professional practice rather than specific codes, though a management code remained in development (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in February 2026 that although the recommendation was accepted in principle, the Handbook to the NHS Constitution gives examples of where codes can be found without expressly referencing them (The Thirlwall Inquiry legal team, Feb 2026).

The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health and Clinical Excellence and, where relevant, the Care Quality Commission, subject to any more specific requirements of their employers.

The Department of Health and Social Care and NHS England recorded the recommendation as completed in February 2026, referring to the latter's 2024 standards of business conduct policy (DHSC and NHS England, Feb 2026). Also in February 2026, the Thirlwall Inquiry legal team found that while the NHS Constitution contains a general requirement for staff to aim to follow relevant guidance, standards and codes, its handbook does not include express reference to them (The Thirlwall Inquiry legal team, Feb 2026).

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication of accurate information about compliance with the fundamental and enhanced standards.

The Department of Health and Social Care and NHS England reported in September 2024 that implementation was ongoing, noting that updated well-led guidance developed with the Care Quality Commission became applicable across all trusts in April 2024 (DHSC and NHS England, Feb 2026). They stated that provider licence conditions regarding governance had also been extended to NHS trusts in April 2023 (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that requirements for good governance systems had come into force in April 2015 under regulations made under the Health and Social Care Act 2008 (The Thirlwall Inquiry legal team, May 2024).

All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it is being used to good effect.

In commentary from September 2024, the Department of Health and Social Care and NHS England referred to their response on governance under recommendation 14 (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team observed that although requirements for good governance systems took effect through regulations in April 2015, it was not clear that this amounted to one comprehensive standard covering all required elements (The Thirlwall Inquiry legal team, Feb 2026).

The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. Failure to comply with such standards should be a matter for performance management by commissioners rather than the regulator, although the latter should be charged with enforcing the provision by providers of accurate information about compliance to the public.

In February 2026, the Department of Health and Social Care and NHS England stated that the NHS Standard Contract covers operating standards, meeting quality standards, and continuous improvement, supported by commissioning incentives through the Commissioning for Quality and Innovation framework (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle, relying on existing standards from the National Institute for Health and Care Excellence alongside joint oversight by the Care Quality Commission and Monitor (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance with those standards. It should be responsible not for directly policing compliance with any enhanced standards but for regulating the accuracy of information about compliance with them.

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 the Care Quality Commission enforces fundamental standards mapped to its Single Assessment Framework but does not enforce enhanced standards (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in part, observing that the commission had policed fundamental standards through inspections since April 2015 while commissioners retained responsibility for regulating information regarding enhanced standards (The Thirlwall Inquiry legal team, May 2024).

The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. The regulator must be willing to consider individual cases of gross failure as well as systemic causes for concern.

The Department of Health and Social Care and NHS England reported in September 2024, in an update published in February 2026, that the recommendation was superseded, stating that monitoring data quality is covered under the Care Quality Commission's Single Assessment Framework alongside statutory duty of candour rules (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that earlier government responses made no mention of placing the commission under a duty to monitor the accuracy of provider disclosures (The Thirlwall Inquiry legal team, May 2024). The department had previously accepted the recommendation in principle in November 2013, concluding that existing regulatory powers and surveillance systems made establishing a new statutory duty unnecessary (Department of Health response, Nov 2013).

The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance with both fundamental and enhanced standards can be measured. These measures should include both outcome and process based measures, and should as far as possible build on information already available within the system or on readily observable behaviour.

In September 2024, the Department of Health and Social Care and NHS England reported that an April 2021 memorandum of understanding between the National Institute for Health and Care Excellence and the Care Quality Commission establishes a framework to align clinical guidance and quality standards with regulatory assessment frameworks (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle, recording earlier actions by the government to introduce developmental statements and establish joint working between the organisations (The Thirlwall Inquiry legal team, May 2024).

Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.

The Department of Health and Social Care and NHS England stated in September 2024 that the government had introduced the special measures regime and the Care Quality Commission had set out its enforcement policy online (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle and recorded the department's earlier updates regarding regulatory intervention powers and special measures (The Thirlwall Inquiry legal team, May 2024).

Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that "current arrangements meet this recommendation", explaining that the national Recovery Support Programme had replaced earlier special measures regimes to assist trusts facing difficult challenges (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had originally accepted the recommendation in principle, citing previous updates regarding enforcement notices, improvement directors, and buddying arrangements (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was superseded, stating that the Care Quality Commission had moved away from mandated returns outside adult social care and, although empowered to compel complaints details during assessments, does not routinely require complaints data from healthcare providers (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle and summarised previous government updates regarding access to complaints information (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency's functions in June 2012 to the NHS Commissioning Board.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that under a redesigned National Patient Safety Alerts system, alerts note that failure to take required actions may lead to Care Quality Commission regulatory action, and the commission uses compliance indicators in assessments (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle, observing that the government maintained providers retain accountability for implementing alerts rather than the regulator overseeing individual decisions (The Thirlwall Inquiry legal team, May 2024).

Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be derived has been successfully implemented.

In February 2026, the Department of Health and Social Care and NHS England reported that this function transferred to NHS England under the Patient Safety Incident Response Framework, which removed the serious incident classification, with the Care Quality Commission assessing providers against incident response standards during inspections (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been partially accepted, reviewing government statements that explained the regulator relied on risk indicators rather than examining every individual incident of avoidable harm (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England regarded the recommendation as superseded, explaining that a statutory medical examiner system took effect in September 2024 to scrutinise non-coronial healthcare deaths (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the Care Quality Commission and the Coroners’ Society of England and Wales had agreed a Memorandum of Understanding requiring coroners to notify the regulator of inquests involving care concerns (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.

The Department of Health and Social Care and NHS England stated in September 2024, in an update published in February 2026, that the Care Quality Commission involves governors in inspections and holds induction sessions with groups of them when they are appointed (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the recommendation had been accepted in principle, recording that the commission's methodology would invite relevant councils of governors to contribute evidence as part of an inspection (The Thirlwall Inquiry legal team, May 2024).

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.

The Inquiry recommended that the Care Quality Commission consider appointing professional and patient board members. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the commission was considering its response alongside wider operational reviews, with work remaining ongoing while further reports were awaited (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation in principle and that advisory groups had been established (The Thirlwall Inquiry legal team, May 2024).

The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.

The Inquiry recommended transferring healthcare provider governance and director oversight to a single regulator. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that trusts must ensure directors meet fitness standards, with the Care Quality Commission (CQC) holding powers to enforce compliance against trusts (DHSC and NHS England, Feb 2026). The department noted that the commission cannot disbar or directly regulate individual directors, observing that "the nature and scope of further implementation may need to be considered" (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in May 2024 that the fitness regulations did not apply to foundation trust governors and left direct enforcement to individual trusts (The Thirlwall Inquiry legal team, May 2024).

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its obligations and to represent the public interest. They should produce an agreed published description of the role of the governors and how it is planned that they perform it. Monitor and the Care Quality Commission should review these descriptions and promote what they regard as best practice.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented and closed, stating that the government did not seek to prescribe how governors should work day to day and that regulators would not agree descriptions agreed between boards and governors (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been accepted in part by the government, noting that Monitor and the Care Quality Commission would not review descriptions agreed between them (The Thirlwall Inquiry legal team, May 2024).

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper persons for the role. Such a test should include a requirement to comply with a prescribed code of conduct for directors.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented under 2014 regulations, while noting that a framework evaluation was planned for 2025 alongside ongoing work on a wider management code of practice (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle and introduced a fit and proper persons test for registered providers (The Thirlwall Inquiry legal team, May 2024).

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications in the standard terms of a foundation trust's constitution.

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 closed, noting that the relevant fitness requirement was enacted as regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle, observing its view that improving existing recruitment and exit procedures should be the focus rather than the constitutions of foundation trusts (The Thirlwall Inquiry legal team, May 2024).

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is not a fit and proper person to hold such a post, licensed bodies should be obliged by the terms of their licence to report the matter to Monitor, the Care Quality Commission and the NHS Trust Development Authority.

In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation had been superseded by the Kark Review, noting that while a standardised board member reference was published in August 2023, it does not appear to implement elements relating to settlement or confidentiality agreements (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team observed that the government had accepted the recommendation in principle, preferring improved references to a regulatory register of concerns (The Thirlwall Inquiry legal team, May 2024).

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences or a new offence containing comparable provisions should be created under which the Care Quality Commission has power to launch a prosecution.

In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was completed, noting that the Care Quality Commission holds powers to prosecute breaches under the Health and Social Care Act 2008 regulations and in respect of unregistered providers (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team observed that the commission was not given the power to prosecute 1974 Act offences, but had received powers to prosecute offences under regulations introduced in 2014 and 2015 (The Thirlwall Inquiry legal team, May 2024).

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on the consistency of trusts' practice in reporting fatalities and other serious incidents.

The Department of Health and Social Care and NHS England stated in September 2024 that the recommendation was implemented and closed, reporting that the Care Quality Commission has a Memorandum of Understanding with the Health and Safety Executive covering statutory incident notifications (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle and that an agreement between the two regulators had been concluded in December 2017 (The Thirlwall Inquiry legal team, May 2024).

Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was addressed through regulations and revised memorandums of understanding with the Health and Safety Executive, with patient safety incident reports provided to the Care Quality Commission (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that under a December 2017 agreement, the two regulators had arranged to notify each other about incidents within their respective jurisdictions and share relevant intelligence (The Thirlwall Inquiry legal team, May 2024).

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards at least as rigorous as those required by the NHS Litigation Authority.

In February 2026, the Department of Health and Social Care and NHS England stated that the NHS Litigation Authority, now NHS Resolution, had moved away from assessment against risk management standards and introduced a Maternity Incentive Scheme in 2017 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle, having shifted from risk management standards toward Care Quality Commission ratings (The Thirlwall Inquiry legal team, May 2024). Earlier, the department reported in February 2015 that assessments against the discontinued standards ceased in April 2014, with inspection regimes applying across all registered providers regardless of indemnity scheme membership (Department of Health, Feb 2015).

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that effective risk assessments take place when changes to the numbers or skills of staff are under consideration. It should also consider how more outcome based standards could be designed to enhance the prospect of exploring deficiences in risk management, such as occurred at the Trust.

The Department of Health and Social Care and NHS England reported in February 2026, in commentary from September 2024, that NHS Resolution adopts guidance on staffing and activity levels in higher risk areas through its Maternity Incentive Scheme, though it noted that this scheme does not extend beyond maternity and perinatal care (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team observed that the recommendation had been accepted only in principle, with risk management standards discontinued in April 2014 and the government maintaining that introducing staffing requirements was a matter for trusts rather than the litigation authority (The Thirlwall Inquiry legal team, May 2024).

The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.

In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as superseded, stating that the National Patient Safety Agency no longer exists and its functions were transferred into the NHS Commissioning Board in June 2012 (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that those functions were subsequently transferred to NHS Improvement in April 2016 and retransferred to NHS England in July 2022 (The Thirlwall Inquiry legal team, May 2024).

Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.

In commentary from September 2024, the Department of Health and Social Care and NHS England stated that the recommendation had been superseded, explaining that the Learn from Patient Safety Events service replaced the National Reporting and Learning System alongside the Patient Safety Incident Response Framework and the statutory duty of candour (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team noted that the government had originally accepted the proposal only in principle, opting not to introduce a mandatory reporting system but rather to rely on the duty of candour and measures promoting voluntary incident reporting (The Thirlwall Inquiry legal team, Feb 2026).

The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the National Reporting and Learning System had been superseded by LPSFE (DHSC and NHS England, Feb 2026). They explained that the LFPSE service was in a public-beta stage, with plans to introduce simple online forms and a new public dashboard (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle while work was considered to make direct incident reporting more accessible (The Thirlwall Inquiry legal team, May 2024).

Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.

In September 2024, the Department of Health and Social Care and NHS England stated that the recommendation had been superseded, explaining that "the designation of 'serious incident' has been abolished in the NHS" and incident recording is managed through the Learn from Patient Safety Events service (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team noted that the government had originally accepted the recommendation only in principle while rejecting a mandatory reporting system (The Thirlwall Inquiry legal team, Feb 2026).

Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; Subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion; A complaint raises substantive issues of professional misconduct or the performance of senior managers; A complaint involves issues about the nature and extent of the services commissioned.

In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that the recommendation was partially implemented, noting that guidance under the Patient Safety Incident Response Framework sets requirements for healthcare providers to determine an investigation's appropriate level of independence (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in part, recording that ministers did not consider independent investigations appropriate in all cases where expert clinical opinion was required (The Thirlwall Inquiry legal team, May 2024).

A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.

In September 2024, the Department of Health and Social Care and NHS England reported that local authorities are legally required to arrange independent advocacy services, adding that the Parliamentary and Health Service Ombudsman signposts complainants to specialist independent advice and support (DHSC and NHS England, Feb 2026). In an implementation review published in February 2026, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation only in part, maintaining that advocacy commissioning was a local authority responsibility and that access to clinical advice should depend on individual circumstances (The Thirlwall Inquiry legal team, Feb 2026).

Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible, the summary should be shared confidentially with the Commissioner and the Care Quality Commission.

The Inquiry recommended that healthcare providers publish summaries of upheld patient care complaints on their websites. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the department had "not taken forward this recommendation as set out", pointing instead to statutory annual complaints reporting and decision summaries published by the Ombudsman (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in part in 2014 but had not explicitly addressed its planned reconsideration regarding serious complaints (The Thirlwall Inquiry legal team, May 2024).

Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board to undertake the support and oversight role of GPs in this area, and be given the resources to do so.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented, noting that GP practices submit annual complaint summaries but integrated care boards have no specific oversight role for primary care complaints while an assurance process is finalised (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted only in part, observing that ministers had rejected universal real-time reporting to avoid a significant bureaucratic burden (Department of Health response, Nov 2013; The Thirlwall Inquiry legal team, May 2024).

Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to very distressed and anxious members of the public; Swift identification of persons of independence, authority and expertise to lead investigations and reviews; A procedure for the recruitment of clinical and other experts to review cases; A communications strategy to inform and reassure the public of the processes being adopted; Clear lines of responsibility and accountability for the setting up and oversight of such reviews. Such events are of sufficient rarity and importance, and requiring of coordination of the activities of multiple organisations, that the primary responsibility should reside in the National Quality Board.

The Department of Health and Social Care and NHS England stated in September 2024 that the government had rejected part of the recommendation, explaining that the national Recovery Support Programme had replaced earlier special measures to assist trusts facing severe challenges (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle in 2014, but had rejected assigning oversight to the National Quality Board in favour of existing regulatory processes (The Thirlwall Inquiry legal team, May 2024).

The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is commissioning. In relation to each such standard, it should agree a method of measuring compliance and redress for non-compliance. Commissioners should consider whether it would incentivise compliance by requiring redress for individual patients who have received sub-standard service to be offered by the provider. These must be consistent with fundamental standards enforceable by the Care Quality Commission.

The Department of Health and Social Care and NHS England stated in September 2024 that the NHS Standard Contract for 2024/25 enables commissioners to agree enhanced local quality requirements, though the clawback element of the quality incentive scheme was paused while a wider review of incentives was undertaken (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle but decided after consultation not to require individual patient redress (The Thirlwall Inquiry legal team, May 2024).

Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, while respecting the principle that it is the provider who has primary responsibility to process and respond to complaints about its services.

In February 2026, the Department of Health and Social Care and NHS England stated that complaint handling standards are a contractual requirement under the NHS standard contract, adding that work was underway to refresh the oversight and assurance process for integrated care board complaints handling (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation only in principle, having raised concerns that allowing commissioning bodies to intervene in individual complaints would create uncertainty over roles and responsibilities (The Thirlwall Inquiry legal team, May 2024).

Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should be a membership system whereby eligible members of the public can be involved in and contribute to the work of the commissioners. There should be lay members of the commissioner's board. Commissioners should create and consult with patient forums and local representative groups. Individual members of the public (whether or not members) must have access to a consultative process so their views can be taken into account. There should be regular surveys of patients and the public more generally. Decision-making processes should be transparent: decision-making bodies should hold public meetings. Commissioners need to create and maintain a recognisable identity which becomes a familiar point of reference for the community.

The Department of Health and Social Care and NHS England stated in September 2024 that the Health and Care Act 2022 replaced clinical commissioning groups with integrated care boards, which must follow statutory guidance on community partnership and undergo annual assessments of their public involvement duties (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had originally accepted the recommendation in part, reviewing earlier measures such as lay governing body members, citizen assemblies, and regular patient surveys (The Thirlwall Inquiry legal team, May 2024).

Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its retained individual responsibility to take whatever action within its power is necessary in the interests of patient safety.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England referred to their update on the Patient Safety Incident Response Framework, considering the recommendation superseded (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation in principle, citing mechanisms under the NHS Standard Contract and regulatory powers enabling intervention when patient safety is at risk (The Thirlwall Inquiry legal team, May 2024).

Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the money. Transparent respect for the independence of Local Healthwatch should not be allowed to inhibit a responsible local authority – or Healthwatch England as appropriate – intervening.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented, reiterating that the government did not accept requiring local authorities to pass over centrally provided funds while noting that Healthwatch England publishes annual funding reports (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation only in part, leaving funding allocations to local authorities while relying on annual reporting to ensure transparency (The Thirlwall Inquiry legal team, May 2024).

Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger and follow up inspections where appropriate, rather than receiving reports without comment or suggestions for action.

The Inquiry recommended giving scrutiny committees powers to inspect healthcare providers or trigger inspections. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that health overview and scrutiny committee principles published in July 2022 set expectations for information sharing and evidence requests, without mentioning inspection powers (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in February 2026 that the government accepted the recommendation in principle, having concluded that granting local authorities additional inspection powers would be duplicative and burdensome (The Thirlwall Inquiry legal team, Feb 2026).

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.

In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle, recording that the government had stated it was not for ministers to advise individual MPs on complaint systems but that correspondence could be shared with regulators with informed consent (The Thirlwall Inquiry legal team, May 2024).

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between the deanery, commissioners, the General Medical Council, the Care Quality Commission and Monitor with regard to patient safety issues must be reviewed to ensure that each organisation is made aware of matters of concern relevant to their responsibilities.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England noted action taken following the inquiry, referring to recommendation 35 for detail on the regulatory landscape and how organisations work together (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that while Health Education England was added in April 2015 to the statutory list of bodies subject to a duty to cooperate, no other medical education and training regulators had been added (The Thirlwall Inquiry legal team, May 2024). The legal team also noted that operational protocols and memoranda of understanding covering information sharing had been established between the Care Quality Commission, the General Medical Council, and other oversight bodies (The Thirlwall Inquiry legal team, May 2024).

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision of the same. Consideration should be given to empowering the General Medical Council to charge organisations a fee for approval.

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 General Medical Council Approved Practice Setting requirements took effect in June 2014 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the council had introduced the new requirements to align with existing statutory duties (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in February 2015 that adopting this model meant empowering the regulator to charge approval fees was no longer relevant (Department of Health, Feb 2015).

The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.

In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, noting action taken by the General Medical Council (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the council had reviewed the Approved Practice Setting scheme and introduced replacement requirements in June 2014 to align with statutory Responsible Officer regulations (The Thirlwall Inquiry legal team, May 2024).

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view in particular to provision for active exchange of relevant information with the healthcare systems regulator, coordination of monitoring processes with others required for medical education and training, and receipt of relevant information from registered practitioners of their current experience in approved practice settings approved establishments.

In commentary published in February 2026, the Department of Health and Social Care and NHS England noted action taken by the General Medical Council and classified the recommendation as implemented and closed (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in May 2024 that the council had replaced the scheme with new requirements in June 2014, aligning practice settings with the Responsible Officer Regulations (The Thirlwall Inquiry legal team, May 2024). The department previously reported in February 2015 that while these requirements were in place, related legislative proposals would be brought forward when parliamentary time allowed (Department of Health, Feb 2015).

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments with a view to ensuring that the General Medical Council (or if considered to be more appropriate, the healthcare systems regulator) has the power to inspect establishments, either itself or by an appointed entity on its behalf, and to require the production of relevant information.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented and closed, stating that the General Medical Council embedded approved practice settings within the Responsible Officer Regulations in June 2014 (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team noted in May 2024 that the government accepted the proposal in principle, reviewing the 2014 changes alongside the Care Quality Commission's existing powers to inspect premises (The Thirlwall Inquiry legal team, May 2024).

The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for post graduate training.

The Department of Health and Social Care and NHS England recorded in September 2024 that the recommendation was implemented and closed, referring to their response to recommendation 167 (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the proposal had been accepted in principle, with new Approved Practice Setting requirements introduced in June 2014 following a review by the General Medical Council (The Thirlwall Inquiry legal team, May 2024). The department had reported in February 2015 that these requirements aligned practice settings with responsible officer regulations, while broader statutory reforms awaited parliamentary time (Department of Health, Feb 2015).

The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation between them and healthcare systems regulators.

In February 2026, the Department of Health and Social Care and NHS England stated that the NHS's first Patient Safety Syllabus had been published, associated training courses had been designed to help regulators, providers, and commissioners identify safety issues, and a Joint Strategic Oversight Group had been established to coordinate regulatory action (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle, summarising past updates on cooperation and information sharing between professional regulators and the Care Quality Commission (The Thirlwall Inquiry legal team, May 2024).

The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly include and are consistent with above principles and these recommendations.

The Department of Health and Social Care and NHS England reported in September 2024 that the NHS Constitution, updated in February 2024, advises staff to aim to be open with patients if anything goes wrong, and that the national terms and conditions handbook requires local appraisals to be consistent with the constitution (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted the government's position that incorporating a duty of candour into employment contracts was not relevant due to definition difficulties, having argued the recommendation was better addressed through appraisal arrangements (The Thirlwall Inquiry legal team, May 2024).

A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to provide such information and explanation as the patient reasonably may request; On registered medical practitioners and registered nurses and other registered professionals who believe or suspect that treatment or care provided to a patient by or on behalf of any healthcare provider by which they are employed has caused death or serious injury to the patient to report their belief or suspicion to their employer as soon as is reasonably practicable. The provision of information in compliance with this requirement should not of itself be evidence or an admission of any civil or criminal liability, but non-compliance with the statutory duty should entitle the patient to a remedy.

The Inquiry recommended statutory duties of candour for healthcare providers and registered professionals. The Department of Health and Social Care (DHSC) and NHS England stated in commentary of September 2024, published in February 2026, that a statutory duty applies to regulated healthcare providers and can be enforced by the Care Quality Commission (CQC), while the obligation for individual professionals remains non-statutory (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry found that "the discharge of the duty of candour, organisational and professional, is patchy" (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).

The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in particular, candidates' attitudes towards caring, compassion and other necessary professional values.

The Inquiry asked the Nursing and Midwifery Council to consider an aptitude test for compassion. The Department of Health and Social Care (DHSC) and NHS England, in commentary of September 2024 published in February 2026, reported that the regulator reviewed entry criteria and updated pre-registration standards to emphasise compassionate care, concluding that these requirements "negate the need for a specific aptitude test" (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that no aptitude test appeared to have been established for nurses trained in England (The Thirlwall Inquiry legal team, May 2024).

The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.

In February 2026, the Department of Health and Social Care and NHS England reported that the Nursing and Midwifery Council had evaluated an aptitude test but decided against it due to barriers of cost, scalability, and affordability, concluding that revised pre-registration standards removed the need for a common examination (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that it was unclear whether the council had considered or acted upon the recommendation (The Thirlwall Inquiry legal team, May 2024).

There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of compassionate care.

In February 2026, the Department of Health and Social Care and NHS England reported that implementation was complete, explaining that the Nursing and Midwifery Council undertakes education quality assurance to ensure programmes meet required standards, alongside wider reviews of undergraduate nursing degrees (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that while local preceptorship standards had been developed, it was "unclear what further was done" to ensure newly qualified nurses were competent at the point of registration (The Thirlwall Inquiry legal team, May 2024).

The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.

The Inquiry called for a Responsible Officer for nursing accountable to the regulatory body. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the appointment of a Responsible Officer was not introduced, but the Nursing and Midwifery Council (NMC) established a role to confirm that revalidation requirements are met (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the NMC had introduced its revalidation scheme without Responsible Officers in April 2016 (The Thirlwall Inquiry legal team, May 2024).

Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They could be required to report to the Nursing and Midwifery Council on their performance on a regular basis.

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, reporting that revalidation had been introduced for all nurses and midwives in the UK to maintain their registration with the Nursing and Midwifery Council (DHSC and NHS England, Feb 2026). Prior to this, the Thirlwall Inquiry legal team found in May 2024 that the council had published a revised Code effective from March 2015, following earlier work by NHS Employers to support values-based appraisal and performance management (The Thirlwall Inquiry legal team, May 2024).

As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice and its implementation. Alongside developmental requirements, this should contain documented evidence of recognised training undertaken, including wider relevant learning. It should also demonstrate commitment, compassion and caring for patients, evidenced by feedback from patients and families on the care provided by the nurse. This portfolio and each annual appraisal should be made available to the Nursing and Midwifery Council, if requested, as part of a nurse's revalidation process. At the end of each annual assessment, the appraisal and portfolio should be signed by the nurse as being an accurate and true reflection and be countersigned by their appraising manager as being such.

The Inquiry recommended mandatory annual performance appraisals and learning portfolios for all nurses. In commentary of September 2024 published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the Nursing and Midwifery Council (NMC) revalidation process requires continuing professional development, reflective discussions, and health declarations (DHSC and NHS England, Feb 2026). That update addressed revalidation and e-portfolios, but did not mention patient feedback or countersigned appraisals named in the recommendation (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government accepted the recommendation in principle and that nursing revalidation was introduced in April 2016 (The Thirlwall Inquiry legal team, May 2024).

Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about the care plans relating to every patient on his or her ward. They should make themselves visible to patients and staff alike, and be available to discuss concerns with all, including relatives. Critically, they should work alongside staff as a role model and mentor, developing clinical competencies and leadership skills within the team. As a corollary, they would monitor performance and deliver training and/or feedback as appropriate, including a robust annual appraisal.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the Royal College of Nursing publishes workforce standards for nurse leads, guidance on supervision models is available, and Professional Nurse Advocates "are in the process of being rolled out" (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation in principle without mandating that ward nurse managers operate solely in a supervisory capacity (The Thirlwall Inquiry legal team, May 2024).

Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all NHS healthcare provider organisations that should be required under commissioning arrangements by those buying healthcare services to arrange such training for appropriate staff.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that eight national development programmes existed for entry level to mid-level managers, including nurses, which train around 20,000 participants annually, alongside leadership programmes offered by the RCN (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in part, having recorded that training arrangements remained primarily the responsibility of providers rather than mandatory commissioning requirements (The Thirlwall Inquiry legal team, May 2024).

Consideration should be given to the creation of a status of Registered Older Person's Nurse.

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that Health Education England funded an Older Persons Fellowship at King's College London, awarding completing students a postgraduate certificate in advanced practice (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in part, choosing to review nurse training and pilot the fellowship programme in 2015 to 2016 rather than create a registered older person's nurse status (The Thirlwall Inquiry legal team, May 2024).

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that trust and foundation trust boards, with limited exceptions, are required by regulation to include a nurse or midwife executive director, with governance assured under the Care Quality Commission's Well-led framework (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation was originally accepted only in part, observing that regulations required clinical commissioning groups to include a nurse on governing bodies though not necessarily at executive level (The Thirlwall Inquiry legal team, May 2024).

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety of any proposed major change to nurse staffing arrangements or provision facilities, and to record whether they accepted or rejected the advice, in the latter case recording its reasons for doing so.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that provider trust boards are required to include an executive nurse or midwife director, subject to narrow exceptions, alongside a 2023 governance code on managing risk (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team previously found in May 2024 that although the recommendation was accepted in principle, it remained unclear whether NHS England ever required nursing and medical directors to sign off on staffing changes and service provision (The Thirlwall Inquiry legal team, May 2024).

There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.

In commentary submitted in September 2024, the Department of Health and Social Care and NHS England stated that work was ongoing, pointing to updated workwear guidance, RCN Workforce Standards, and a national project led by NHS Supply Chain to standardise clinical uniforms, while noting that local uniform policy remains the responsibility of local organisations (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle, observing that the government had pointed to a review recommending that support workers could use the title "Nursing Assistant" upon completing fundamental care training (The Thirlwall Inquiry legal team, May 2024).

Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the development of local uniform policy remains the responsibility of local organisations, pointing to guidance supporting the use of uniforms, name badges, and staff introductions (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had only been accepted in principle, observing that no mandatory uniform requirement had been set because trusts develop their own (The Thirlwall Inquiry legal team, May 2024).

A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader would be expected to have.

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England recorded progress as ongoing, referring to their response on the Leadership Competency Framework for further detail (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented, noting the NHS Leadership Academy's healthcare leadership model published in November 2013 (The Thirlwall Inquiry legal team, May 2024). The department had previously reported the recommendation complete in February 2015 after that model and new fit and proper persons regulations were established (Department of Health, Feb 2015).

An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this would be greater if it were thought appropriate to extend a regulatory requirement to a wider range of managers and leaders. The proportionality of such a step could be better assessed after reviewing the experience of a licensing provision for directors.

The Inquiry proposed considering an independent professional regulator for healthcare managers. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the department was exploring options to introduce professional standards for National Health Service (NHS) managers and bring them into regulation (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry found it unclear how regulating senior managers would professionalise leadership generally, except as a first step toward wider regulation (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).

A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, at least initally, the objective should be to require all leadership posts to be filled by persons who experience some shared training and obtain the relevant accreditation, enhancing the spread of the common culture and providing the basis for a regulatory regime.

In February 2026, DHSC and NHS England stated that implementation remained ongoing, reporting that the NHS Leadership Academy provides eight national development programmes including some accredited courses to approximately 20,000 participants annually, with wider stakeholder engagement on a leadership competency framework planned for autumn and winter 2024/25 (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had partially accepted the recommendation by establishing leadership development programmes while rejecting the need for a formal accreditation scheme (The Thirlwall Inquiry legal team, May 2024).

If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater resources, or better cooperation with the Care Quality Commission and other organisations such as the Royal Colleges to ensure that it is provided with the appropriate information.

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the General Medical Council entered into an information sharing agreement with the Academy of Medical Royal Colleges in September 2016 and participates in the Joint Strategic Oversight Group to share intelligence and coordinate regulatory action (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle and recorded the regulator's operational protocols with the Care Quality Commission (The Thirlwall Inquiry legal team, May 2024).

To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled to work closely with the systems regulators and to share their information and analyses on the working of systems in organisations in which nurses are active. It should not have to wait until a disaster has occurred to intervene with its fitness to practise procedures. Full access to the Care Quality Commission information in particular is vital.

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, reporting that the Nursing and Midwifery Council had established a Regulatory Intelligence Unit, enhanced data-sharing protocols, and was reviewing its memorandum of understanding with the Care Quality Commission (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in part, recording that the nursing regulator did not seek a direct role in investigating systems issues because primary responsibility lay with other oversight bodies (The Thirlwall Inquiry legal team, May 2024).

The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide to seek the cooperation of the Care Quality Commission, but as an independent regulator it must be empowered to act on its own if it considers it necessary in the public interest. This will require resources in terms of appropriately expert staff, data systems and finance. Given the power of the registrar to refer cases without a formal third party complaint, it would not appear that a change of regulation is necessary, but this should be reviewed.

In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented, noting that while the Nursing and Midwifery Council did not support directly investigating systems issues, it introduced a Regulatory Intelligence Unit in 2020 and an internal pre-case enquiries policy in January 2024 (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team observed in May 2024 that the council did not support being tasked directly with investigating systems issues, pointing to the distinct roles of professional and systems regulators (The Thirlwall Inquiry legal team, May 2024).

The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising out of the same event or series of events but involving professionals regulated by more than one body. While it would require new regulations, consideration should be given to the possibility of moving towards a common independent tribunal to determine fitness to practise issues and sanctions across the healthcare professional field.

In February 2026, the Department of Health and Social Care and NHS England stated that an independent tribunal set up to take over hearings was abolished in 2012, and individual statutory regulators continue to operate separate fitness to practise processes overseen by the Professional Standards Authority (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in part, recording that the Law Commission had proposed a draft Bill to establish a single regulatory framework (The Thirlwall Inquiry legal team, May 2024). In February 2015, the department stated that the government agreed legislation should empower regulators to work together, reporting that legislation would be brought forward when parliamentary time allowed (Department of Health, Feb 2015).

Each provider organisation should have a board level member with responsibility for information.

In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the Records Management Code of Practice confirms a designated staff member of appropriate seniority should hold lead responsibility for records management (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation in principle, leaving trusts to agree individual board roles locally while the department supported executive directors taking principal responsibility for providing information (The Thirlwall Inquiry legal team, May 2024).

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account to be true, or alternatively a statement of explanation as to the reason any such director is unable or has refused to sign such a declaration.

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 although it was accepted in part, the government later concluded that accountability was better served by enabling Healthwatch to challenge quality accounts locally (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had only partially accepted the proposal because existing regulations required an authorised statement on behalf of the provider rather than separate signatures from every director (The Thirlwall Inquiry legal team, May 2024).

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of fact concerning an item of prescribed information which he/she does not have reason to believe is true at the time of making the declaration.

The Inquiry called for a criminal offence for directors signing false quality account declarations. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the Thirlwall Inquiry had noted action taken in response to the recommendation (DHSC and NHS England, Feb 2026). That inquiry's legal team recorded in May 2024 that the government enacted a wider offence of false or misleading information under section 92 of the Care Act 2014, applying to care providers and to senior individuals who consent to or connive in the offence (The Thirlwall Inquiry legal team, May 2024).

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. In the event of an organisation failing to take that action, the regulator should be able to issue its own statement of correction.

In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the Health Act 2009 requires providers to republish quality accounts within 21 days if notified of errors by the Care Quality Commission or NHS England (DHSC and NHS England, Feb 2026). Both bodies also reported that a National Quality Board review to determine how quality accounts could be improved was "temporarily paused" (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team observed that the government had originally accepted the recommendation in principle while focusing on provider and auditor responsibilities, without addressing the role of regulators (The Thirlwall Inquiry legal team, May 2024).

The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the agreement of the devolved governments, the United Kingdom. The information functions previously held by the National Patient Safety Agency should be transferred to the NHS Information Centre if made independent.

In February 2026, the Department of Health and Social Care and NHS England referred 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 accepted the recommendation in principle by making the Health and Social Care Information Centre an executive non-departmental public body, but had declined to transfer former National Patient Safety Agency functions (The Thirlwall Inquiry legal team, May 2024). Earlier, the department reported in February 2015 that work to re-commission the National Reporting and Learning System was underway (Department of Health, Feb 2015).

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied to, and processed by, the Information Centre and, through them, made publicly available in the same way as other quality related information.

The Department of Health and Social Care and NHS England stated in September 2024 that implementation was ongoing, with provisional Never Events data published monthly (DHSC and NHS England, Feb 2026). However, they noted that publishing rolling twelve-month incident data remained paused while considering future publications in line with LFPSE (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation in principle, summarising earlier updates on incident reporting systems (The Thirlwall Inquiry legal team, Feb 2026).

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified in the public interest.

The Department of Health and Social Care and NHS England stated in commentary from September 2024 that the recommendation was implemented and closed, noting that Schedule 5 of the Coroners and Justice Act 2009 empowers coroners to order disclosure of relevant evidence (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found evidence of implementation, observing that the government had accepted the proposal in principle in 2013 but declined to incorporate information sharing into Care Quality Commission registration requirements (Department of Health response, Nov 2013; The Thirlwall Inquiry legal team, May 2024).

It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.

The Inquiry recommended that medical examiners be independent of organisations whose patient deaths they scrutinise. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that medical examiners had been introduced and that National Medical Examiner good practice guidelines issued in 2020 cover requirements to maintain independence, adding that operational arrangements at employing NHS bodies must support their independent role (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry found that medical examiners cannot review a patient whom they have treated or where a conflict of interest exists, such as a death occurring in their own working unit (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).