Public Inquiry

Mid Staffordshire NHS Foundation Trust Public Inquiry

Status: Completed Chair: Robert Francis QC Established: Jun 2010 Report: Feb 2013 Commissioned by: Department of Health and Social Care

Public inquiry into the serious failings in care at Mid Staffordshire NHS Foundation Trust between 2005-2009, where patients were routinely neglected and standards of care were appalling. The Francis Report made 290 recommendations for fundamental culture change to put patients …

Response breakdown

290 recommendations total

69%

28%

201 (69%) — Accepted

80 (28%) — Accepted in Part

9 (3%) — Not Accepted

Blanket response: Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.

Evidence & impact

AI-generated · 26 Mar 2026

The Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Sir Robert Francis QC, examined failures in care at Stafford Hospital between 2005 and 2009. The inquiry's report, published in February 2013, made 290 recommendations aimed at preventing similar failures across the NHS.

The government responded through two documents: 'Patients First and Foremost' in March 2013 and 'Hard Truths: the Journey to Putting Patients First' in November 2013. According to these responses, the government accepted 201 recommendations (69%), accepted in principle 60 recommendations (21%), partially accepted 20 recommendations (7%), and did not accept 9 recommendations (3%).

The government response identified several key reforms, including establishing a new Chief Inspector of Hospitals, strengthening the Care Quality Commission's inspection regime, introducing a statutory duty of candour, and implementing a fit and proper person test for NHS directors. The response also referenced the creation of Health Education England and Healthwatch England as part of wider NHS reforms.

However, the available evidence indicates limited published documentation of progress beyond these initial responses. Of the 290 recommendations, 281 (97%) are recorded as 'Awaiting Action' with no formal progress updates or implementation reviews identified in the public record. This suggests that while the government accepted the majority of Francis's recommendations and announced several high-profile reforms, comprehensive evidence of wider implementation across all recommendations has not been published.

The absence of systematic progress reporting makes it difficult to assess which of the accepted recommendations have been acted upon beyond the headline reforms announced in 2013. No formal implementation review has been identified that would provide comprehensive evidence of progress across all 290 recommendations.

Reports & milestones

Reports

06 Feb 2013 0 tracked recs Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Executive Summary · PDF

06 Feb 2013 290 tracked recs Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Tracked recommendations · PDF

06 Feb 2013 0 tracked recs Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Volume 1 · PDF

06 Feb 2013 0 tracked recs Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Volume 2 · PDF

06 Feb 2013 0 tracked recs Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Volume 3 · PDF

Timeline

09 Jun 2010 Inquiry Announced

01 Nov 2010 Inquiry Establish…

06 Feb 2013 Final Report Publ…

Recommendations

201 shown (filtered)

Code	Recommendation	Addressed to	Response
F1	Implementing the recommendations It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this …	Department of Health and Social Care	Accepted	View →
F2	Putting the patient first The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority …	NHS	Accepted	View →
F3	Clarity of values and principles The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common …	Department of Health and Social Care	Accepted	View →
F4	Clarity of values and principles The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients …	Department of Health and Social Care	Accepted	View →
F5	Clarity of values and principles In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; …	Department of Health and Social Care	Accepted	View →
F6	Clarity of values and principles The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their …	Department of Health and Social Care	Accepted	View →
F8	Clarity of values and principles Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for …	Commissioners	Accepted	View →
F11	Fundamental standards of behaviour Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they …	Healthcare providers	Accepted	View →
F12	Fundamental standards of behaviour Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to …	Healthcare providers	Accepted	View →
F13	The nature of standards Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. …	Department of Health and Social Care	Accepted	View →
F16	Responsibility for setting standards The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the …	Department of Health and Social Care	Accepted	View →
F18	Responsibility for setting standards It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and …	Department of Health and Social Care	Accepted	View →
F23	Responsibility for regulating and monitoring compliance The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of …		Accepted	View →
F24	Responsibility for regulating and monitoring compliance Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted …	CQC	Accepted	View →
F25	Responsibility for regulating and monitoring compliance It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, …		Accepted	View →
F26	Responsibility for regulating and monitoring compliance In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take …	CQC	Accepted	View →
F27	Responsibility for regulating and monitoring compliance The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental …	CQC	Accepted	View →
F28	Sanctions and interventions for non-compliance Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable …	CQC	Accepted	View →
F29	Sanctions and interventions for non-compliance It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory …	Department of Health and Social Care	Accepted	View →
F30	Interim measures The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach …	CQC	Accepted	View →
F31	Interim measures Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place …	Monitor	Accepted	View →
F32	Interim measures Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take …	Monitor	Accepted	View →
F35	Need to share information between regulators Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all …	CQC	Accepted	View →
F36	Use of information for effective regulation A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in …	CQC	Accepted	View →
F37	Use of information about compliance by regulator from: Quality accounts Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each …	NHS Trusts	Accepted	View →
F38	Use of information about compliance by regulator from: Complaints The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant …	CQC	Accepted	View →
F40	Use of information about compliance by regulator from: Complaints It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the …	CQC	Accepted	View →
F42	Use of information about compliance by regulator from: Serious untoward inciden… Strategic Health Authorities/their successors should		Accepted	View →
F43	Use of information about compliance by regulator from: Media Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.	CQC	Accepted	View →
F46	Use of information about compliance by regulator from: Quality and risk profiles The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important …	CQC	Accepted	View →
F47	Use of information about compliance by regulator from: Foundation trust governo… The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. …	CQC	Accepted	View →
F49	Enhancement of monitoring and the importance of inspection Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring …	CQC	Accepted	View →
F50	Enhancement of monitoring and the importance of inspection The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.	CQC	Accepted	View →
F51	Enhancement of monitoring and the importance of inspection The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of …	CQC	Accepted	View →
F52	Enhancement of monitoring and the importance of inspection The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage …	CQC	Accepted	View →
F53	Care Quality Commission independence strategy and culture Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a …	Department of Health and Social Care	Accepted	View →
F54	Care Quality Commission independence strategy and culture Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to …	CQC	Accepted	View →
F55	Care Quality Commission independence strategy and culture The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and …	CQC	Accepted	View →
F56	Care Quality Commission independence strategy and culture The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, …	CQC	Accepted	View →
F57	Care Quality Commission independence strategy and culture The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and …	CQC	Accepted	View →
F58	Care Quality Commission independence strategy and culture Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there …	CQC	Accepted	View →
F62	Improved patient focus For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into …	Monitor	Accepted	View →
F63	Improved transparency Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.	Monitor	Accepted	View →
F65	Quality of care as a pre-condition for foundation trust applications The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of …		Accepted	View →
F66	Improving contribution of stakeholder opinions The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to …	Department of Health and Social Care	Accepted	View →
F67	Focus on compliance with fundamental standards The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for …		Accepted	View →
F68	Focus on compliance with fundamental standards No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager …		Accepted	View →
F69	Focus on compliance with fundamental standards The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality …	Monitor	Accepted	View →
F70	Duty of utmost good faith A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant …	Monitor	Accepted	View →
F71	Role of Secretary of State The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a …	Department of Health and Social Care	Accepted	View →
F72	Assessment process for authorisation The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas …	Monitor	Accepted	View →
F73	Need for constructive working with other parts of the system The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with …	Department of Health and Social Care	Accepted	View →
F74	Enhancement of role of governors Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation …	Monitor	Accepted	View →
F76	Enhancement of role of governors Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large …	NHS Trusts	Accepted	View →
F77	Enhancement of role of governors Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to …	NHS England	Accepted	View →
F78	Enhancement of role of governors The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in …	CQC	Accepted	View →
F81	Accountability of providers' directors Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude …	CQC	Accepted	View →
F82	Accountability of providers' directors Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom …	CQC	Accepted	View →
F83	Accountability of providers' directors If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would …	Monitor	Accepted	View →
F85	Accountability of providers' directors Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event …	CQC	Accepted	View →
F86	Requirement of training of directors A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of …	NHS Trusts	Accepted	View →
F90	Assistance in deciding on prosecutions In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences …		Accepted	View →
F92	NHS Litigation Authority Improvement of risk management The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.		Accepted	View →
F94	Evidence-based assessment As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to …		Accepted	View →
F95	Information sharing As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed …		Accepted	View →
F96	Information sharing The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of …		Accepted	View →
F101	National Patient Safety Agency functions While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it …	NHS England	Accepted	View →
F102	Transparency use and sharing of information Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others …	NHS England	Accepted	View →
F103	Transparency use and sharing of information The National Patient Safety Agency or its successor should regularly share information with Monitor.	NHS England	Accepted	View →
F104	Transparency use and sharing of information The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency …	CQC	Accepted	View →
F105	Transparency use and sharing of information Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality …	NHS England	Accepted	View →
F106	Health Protection Agency Coordination and publication of providers' information… The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation …		Accepted	View →
F107	Sharing concerns If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that …		Accepted	View →
F108	Support for other agencies Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in …		Accepted	View →
F109	Effective complaints handling Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, …	Healthcare providers	Accepted	View →
F110	Lowering barriers Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may …	Healthcare providers	Accepted	View →
F111	Lowering barriers Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be …	Healthcare providers	Accepted	View →
F112	Lowering barriers Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of …	Healthcare providers	Accepted	View →
F113	Complaints handling The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be …	NHS	Accepted	View →
F114	Complaints handling Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.	Healthcare providers	Accepted	View →
F116	Support for complainants Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be …	Healthcare providers	Accepted	View →
F119	Learning and information from complaints Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in …	Healthcare providers	Accepted	View →
F121	Learning and information from complaints The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should …	CQC	Accepted	View →
F123	Responsibility for monitoring delivery of standards and quality GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should …		Accepted	View →
F125	Responsibility for requiring and monitoring delivery of enhanced standards In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with …	Commissioners	Accepted	View →
F126	Preserving corporate memory The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the …	NHS England	Accepted	View →
F127	Resources for scrutiny The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny …	NHS England	Accepted	View →
F128	Expert support Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including …	Commissioners	Accepted	View →
F129	Ensuring assessment and enforcement of fundamental standards through contracts In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard …	Commissioners	Accepted	View →
F130	Relative position of commissioner and provider Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be …	Commissioners	Accepted	View →
F131	Development of alternative sources of provision Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken …	Commissioners	Accepted	View →
F132	Monitoring tools Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such …	Commissioners	Accepted	View →
F134	Role of commissioners in provision of support for complainants Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.	Commissioners	Accepted	View →
F136	Public accountability of commissioners and public engagement Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of …	Commissioners	Accepted	View →
F138	Local scrutiny Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at …	Commissioners	Accepted	View →
F139	The need to put patients first at all times The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient …	NHS England	Accepted	View →
F140	Performance managers working constructively with regulators Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant …	NHS England	Accepted	View →
F142	Clear lines of responsibility supported by good information flows For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the …	NHS England	Accepted	View →
F143	Clear metrics on quality Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms …	NHS England	Accepted	View →
F144	Need for ownership of quality metrics at a strategic level The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing …	NHS England	Accepted	View →
F147	Coordination of local public scrutiny bodies Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.	Department of Health and Social Care	Accepted	View →
F148	Training The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well …		Accepted	View →
F149	Expert assistance Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and …		Accepted	View →
F152	Medical training Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the …	Healthcare providers	Accepted	View →
F154	Medical training The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight …	CQC	Accepted	View →
F155	Medical training The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance …	GMC	Accepted	View →
F156	Medical training The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.	GMC	Accepted	View →
F157	Matters to be reported to the General Medical Council The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical …	GMC	Accepted	View →
F158	Training and training establishments as a source of safety information The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from …	GMC	Accepted	View →
F159	Training and training establishments as a source of safety information Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards …	GMC	Accepted	View →
F160	Training and training establishments as a source of safety information Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences …	GMC	Accepted	View →
F161	Training and training establishments as a source of safety information Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source …	GMC	Accepted	View →
F162	Training and training establishments as a source of safety information The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of …	GMC	Accepted	View →
F163	Safe staff numbers and skills The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of …	GMC	Accepted	View →
F170	Health Education England Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.	NHS England	Accepted	View →
F171	Deans All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical …	NHS England	Accepted	View →
F172	Proficiency in the English language The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and …	Department of Health and Social Care	Accepted	View →
F173	Principles of openness transparency and candour Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the …	Healthcare providers	Accepted	View →
F174	Candour about harm Where death or serious harm has been or may have been caused to a patient by an act or omission of the …	Healthcare providers	Accepted	View →
F175	Candour about harm Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a …	Healthcare providers	Accepted	View →
F176	Openness with regulators Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not …	Healthcare providers	Accepted	View →
F177	Openness in public statements Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.	Healthcare providers	Accepted	View →
F179	Restrictive contractual clauses "Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar …	Department of Health and Social Care	Accepted	View →
F180	Candour about incidents Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the …	Healthcare providers	Accepted	View →
F182	Statutory duty of openness and transparency There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare …	Department of Health and Social Care	Accepted	View →
F184	Enforcement by the Care Quality Commission Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute …	CQC	Accepted	View →
F185	Focus on culture of caring There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in …	NMC	Accepted	View →
F186	Practical hands-on training and experience Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all …	NMC	Accepted	View →
F187	Practical hands-on training and experience There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on …	NMC	Accepted	View →
F191	Recruitment for values and commitment Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and …	Healthcare providers	Accepted	View →
F196	Nurse leadership The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient …	Department of Health and Social Care	Accepted	View →
F198	Measuring cultural health Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing …	Healthcare providers	Accepted	View →
F199	Key nurses Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for …	Healthcare providers	Accepted	View →
F201	Strengthening the nursing professional voice The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions …		Accepted	View →
F202	Strengthening the nursing professional voice Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff …	Healthcare providers	Accepted	View →
F203	Strengthening the nursing professional voice A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of …	Department of Health and Social Care	Accepted	View →
F206	Strengthening the nursing professional voice The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a …	Department of Health and Social Care	Accepted	View →
F210	Code of conduct for healthcare support workers There should be a national code of conduct for healthcare support workers.	Department of Health and Social Care	Accepted	View →
F211	Training standards for healthcare support workers There should be a common set of national standards for the education and training of healthcare support workers.	Department of Health and Social Care	Accepted	View →
F214	Shared training A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and …		Accepted	View →
F215	Shared code of ethics A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to …	Department of Health and Social Care	Accepted	View →
F216	Leadership framework The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health …		Accepted	View →
F218	Enforcement of standards and accountability 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 …	CQC	Accepted	View →
F221	Ensuring common standards of competence and compliance Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards …	CQC	Accepted	View →
F222	General Medical Council Systemic investigation where needed The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be …	GMC	Accepted	View →
F224	Information sharing Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue …	GMC	Accepted	View →
F225	Peer reviews The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act …	GMC	Accepted	View →
F228	Administrative reform It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is …	NMC	Accepted	View →
F229	Revalidation It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical …	NMC	Accepted	View →
F230	Profile The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable …	NMC	Accepted	View →
F231	Coordination with internal procedures It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action …	NMC	Accepted	View →
F232	Employment liaison officers The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to …	NMC	Accepted	View →
F233	For joint action Profile While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that …	GMC	Accepted	View →
F234	Cooperation with the Care Quality Commission Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in …	GMC	Accepted	View →
F236	Identification of who is responsible for the patient Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so …	Healthcare providers	Accepted	View →
F237	Teamwork There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by …	Healthcare providers	Accepted	View →
F238	Communication with and about patients Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff …	Healthcare providers	Accepted	View →
F239	Continuing responsibility for care The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be …	Healthcare providers	Accepted	View →
F240	Hygiene All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged …	Healthcare providers	Accepted	View →
F241	Provision of food and drink The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.	Healthcare providers	Accepted	View →
F242	Medicines administration In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse …	Healthcare providers	Accepted	View →
F243	Recording of routine observations The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately …	Healthcare providers	Accepted	View →
F244	Common information practices shared data and electronic records There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. …	NHS	Accepted	View →
F246	Comparable quality accounts Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form …	Department of Health and Social Care	Accepted	View →
F247	Accountability for quality accounts Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems …	Healthcare providers	Accepted	View →
F248	Accountability for quality accounts Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to …	Healthcare providers	Accepted	View →
F252	Access to data It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.	Department of Health and Social Care	Accepted	View →
F253	Access to quality and risk profile The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the …	CQC	Accepted	View →
F254	Access for public and patient comments While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, …	NHS England	Accepted	View →
F255	Using patient feedback Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" …	NHS England	Accepted	View →
F256	Follow up of patients A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a …	Healthcare providers	Accepted	View →
F258	Role of the Health and Social Care Information Centre The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to …		Accepted	View →
F259	Role of the Health and Social Care Information Centre The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should …		Accepted	View →
F261	Information standards The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.		Accepted	View →
F262	Enhancing the use analysis and dissemination of healthcare information All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on …	Healthcare providers	Accepted	View →
F263	Enhancing the use analysis and dissemination of healthcare information It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for …	Healthcare providers	Accepted	View →
F264	Enhancing the use analysis and dissemination of healthcare information In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and …	Royal Colleges	Accepted	View →
F265	Enhancing the use analysis and dissemination of healthcare information The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to …	Department of Health and Social Care	Accepted	View →
F266	Enhancing the use analysis and dissemination of healthcare information In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and …	Department of Health and Social Care	Accepted	View →
F267	Enhancing the use analysis and dissemination of healthcare information All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care …	Healthcare providers	Accepted	View →
F268	Resources Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant …	Healthcare providers	Accepted	View →
F269	Improving and assuring accuracy The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This …	Healthcare providers	Accepted	View →
F270	Improving and assuring accuracy There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the …	Department of Health and Social Care	Accepted	View →
F271	Improving and assuring accuracy To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and …	Department of Health and Social Care	Accepted	View →
F272	Improving and assuring accuracy There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation …	Department of Health and Social Care	Accepted	View →
F274	Information to coroners There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of …	Department of Health and Social Care	Accepted	View →
F276	Independent medical examiners Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the …	Department of Health and Social Care	Accepted	View →
F277	Death certification National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, …	Department of Health and Social Care	Accepted	View →
F278	Death certification It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or …	Healthcare providers	Accepted	View →
F279	Death certification So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or …	Healthcare providers	Accepted	View →
F280	Appropriate and sensitive contact with bereaved families Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances …	Healthcare providers	Accepted	View →
F281	Appropriate and sensitive contact with bereaved families It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how …	Department of Health and Social Care	Accepted	View →
F282	Information for and from inquests Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.	Coroners	Accepted	View →
F283	Information for and from inquests Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the …		Accepted	View →
F284	Appointment of assistant deputy coroners The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.		Accepted	View →
F285	Appointment of assistant deputy coroners The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a …		Accepted	View →
F286	Impact assessments before structural change Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare …	Department of Health and Social Care	Accepted	View →
F287	Impact assessments before structural change The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and …	Department of Health and Social Care	Accepted	View →
F288	Clinical input The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety …	Department of Health and Social Care	Accepted	View →
F289	Experience on the front line Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who …	Department of Health and Social Care	Accepted	View →
F290	Experience on the front line The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, …	Department of Health and Social Care	Accepted	View →