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

80 shown (filtered)

Code	Recommendation	Addressed to	Response
F7	Clarity of values and principles All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both …	NHS	Accepted in Part	View →
F9	Fundamental standards of behaviour The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the …	Department of Health and Social Care	Accepted in Part	View →
F10	Fundamental standards of behaviour The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as …	Department of Health and Social Care	Accepted in Part	View →
F14	The nature of standards In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance …	CQC	Accepted in Part	View →
F15	The nature of standards All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a …	CQC	Accepted in Part	View →
F17	Responsibility for setting standards The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. …	NHS England	Accepted in Part	View →
F20	Responsibility for regulating and monitoring compliance The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the …	CQC	Accepted in Part	View →
F21	Responsibility for regulating and monitoring compliance The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and …	CQC	Accepted in Part	View →
F22	Responsibility for regulating and monitoring compliance The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical …		Accepted in Part	View →
F33	Interim measures Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the …	Department of Health and Social Care	Accepted in Part	View →
F34	Interim measures Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim …	CQC	Accepted in Part	View →
F39	Use of information about compliance by regulator from: Complaints The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.	CQC	Accepted in Part	View →
F41	Use of information about compliance by regulator from: Patient safety alerts The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee …	CQC	Accepted in Part	View →
F44	Use of information about compliance by regulator from: Media Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was …	CQC	Accepted in Part	View →
F45	Use of information about compliance by regulator from: Inquests The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.	CQC	Accepted in Part	View →
F48	Use of information about compliance by regulator from: Foundation trust governo… The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them …	CQC	Accepted in Part	View →
F59	Care Quality Commission independence strategy and culture Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the …	CQC	Accepted in Part	View →
F60	Consolidation of regulatory functions The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be …	Department of Health and Social Care	Accepted in Part	View →
F75	Enhancement of role of governors The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the …	NHS Trusts	Accepted in Part	View →
F79	Accountability of providers' directors There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for …	CQC	Accepted in Part	View →
F80	Accountability of providers' directors A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be …	CQC	Accepted in Part	View →
F84	Accountability of providers' directors Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable …	Healthcare providers	Accepted in Part	View →
F87	Ensuring the utility of a health and safety function in a clinical setting The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should …	Department of Health and Social Care	Accepted in Part	View →
F88	Information sharing The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators …		Accepted in Part	View →
F89	Information sharing Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and …	Healthcare providers	Accepted in Part	View →
F91	NHS Litigation Authority Improvement of risk management The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not …	Department of Health and Social Care	Accepted in Part	View →
F93	NHS Litigation Authority Improvement of risk management The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, …		Accepted in Part	View →
F97	National Patient Safety Agency functions The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this …	NHS England	Accepted in Part	View →
F98	National Patient Safety Agency functions Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm …	NHS England	Accepted in Part	View →
F99	National Patient Safety Agency functions The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative …	NHS England	Accepted in Part	View →
F100	National Patient Safety Agency functions Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt …	CQC	Accepted in Part	View →
F115	Investigations Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint …	Healthcare providers	Accepted in Part	View →
F117	Support for complainants A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.	Department of Health and Social Care	Accepted in Part	View →
F118	Learning and information from complaints Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's …	Healthcare providers	Accepted in Part	View →
F120	Learning and information from complaints Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on …	Commissioners	Accepted in Part	View →
F122	Handling large-scale complaints Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to …		Accepted in Part	View →
F124	Duty to require and monitor delivery of fundamental standards The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in …	Commissioners	Accepted in Part	View →
F133	Role of commissioners in complaints Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to …	Commissioners	Accepted in Part	View →
F135	Public accountability of commissioners and public engagement Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public …	Commissioners	Accepted in Part	View →
F141	Taking responsibility for quality Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and …	NHS England	Accepted in Part	View →
F146	Finance and oversight of Local Healthwatch Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to …		Accepted in Part	View →
F150	Inspection powers Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or …		Accepted in Part	View →
F151	Complaints to MPs MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They …	Parliament	Accepted in Part	View →
F153	Medical training The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of …	Department of Health and Social Care	Accepted in Part	View →
F164	Approved Practice Settings The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate …	GMC	Accepted in Part	View →
F165	Approved Practice Settings The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be …	GMC	Accepted in Part	View →
F166	Approved Practice Settings The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with …	GMC	Accepted in Part	View →
F167	Approved Practice Settings The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of …	GMC	Accepted in Part	View →
F168	Approved Practice Settings The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved …	Department of Health and Social Care	Accepted in Part	View →
F169	Role of the Department of Health and the National Quality Board The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of …	Department of Health and Social Care	Accepted in Part	View →
F178	Implementation of the duty Ensuring consistency of obligations under the duty o… The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and …	Department of Health and Social Care	Accepted in Part	View →
F181	Enforcement of the duty Statutory duties of candour in relation to harm to pati… A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or …	Department of Health and Social Care	Accepted in Part	View →
F188	Aptitude test for compassion and caring The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered …	NMC	Accepted in Part	View →
F189	Consistent training The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.	NMC	Accepted in Part	View →
F190	National standards There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver …	NMC	Accepted in Part	View →
F192	Strong nursing voice The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and …	NMC	Accepted in Part	View →
F193	Standards for appraisal and support Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which …	NMC	Accepted in Part	View →
F194	Standards for appraisal and support As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual …	NMC	Accepted in Part	View →
F195	Nurse leadership Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as …	Healthcare providers	Accepted in Part	View →
F197	Nurse leadership Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse …	NHS	Accepted in Part	View →
F200	Key nurses Consideration should be given to the creation of a status of Registered Older Person's Nurse.	NMC	Accepted in Part	View →
F204	Strengthening the nursing professional voice All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and …	Healthcare providers	Accepted in Part	View →
F205	Strengthening the nursing professional voice Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact …	Commissioners	Accepted in Part	View →
F207	Strengthening identification of healthcare support workers and nurses There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.	Department of Health and Social Care	Accepted in Part	View →
F208	Strengthening identification of healthcare support workers and nurses Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily …	Commissioners	Accepted in Part	View →
F217	Common selection criteria A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn …		Accepted in Part	View →
F219	A regulator as an alternative An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up …	Department of Health and Social Care	Accepted in Part	View →
F220	Accreditation A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, …		Accepted in Part	View →
F223	Enhanced resources If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater …	GMC	Accepted in Part	View →
F226	Nursing and Midwifery Council Investigation of systemic concerns To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council …	NMC	Accepted in Part	View →
F227	Nursing and Midwifery Council Investigation of systemic concerns The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where …	NMC	Accepted in Part	View →
F235	Joint proceedings The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under …		Accepted in Part	View →
F245	Board accountability Each provider organisation should have a board level member with responsibility for information.	Healthcare providers	Accepted in Part	View →
F249	Accountability for quality accounts Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying …	Healthcare providers	Accepted in Part	View →
F250	Accountability for quality accounts It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account …	Department of Health and Social Care	Accepted in Part	View →
F251	Regulatory oversight of quality accounts The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled …	CQC	Accepted in Part	View →
F257	Role of the Health and Social Care Information Centre The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the …		Accepted in Part	View →
F260	Information standards The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in …		Accepted in Part	View →
F273	Information to coroners The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable …	Healthcare providers	Accepted in Part	View →
F275	Independent medical examiners It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.	Department of Health and Social Care	Accepted in Part	View →