Public Inquiry

Muckamore Abbey Hospital Inquiry

Status: Completed Chair: Tom Kark KC Established: Jun 2022 Report: Jun 2026 Commissioned by: Northern Ireland Executive

Statutory public inquiry into systematic abuse of patients with learning disabilities at Muckamore Abbey Hospital, Northern Ireland. 300,000 hours of CCTV footage revealed physical abuse in 2017. 120 sitting days; oral evidence from 181 witnesses. Report published 18 June 2026 …

Response breakdown

106 recommendations total

100%

106 (100%) — Awaiting Response

Reports & milestones

Reports

18 Jun 2026 106 tracked recs Muckamore Abbey Hospital Inquiry Report · Tracked recommendations · PDF

Timeline

05 Nov 2021 Inquiry Announced Health Minister announced a public inquiry into abuse at Muckamore Abbey Hospital.

19 May 2022 Chair Appointed Tom Kark KC appointed as Chair.

03 Oct 2022 Inquiry Launched Inquiry formally launched. · Source

19 Jun 2023 Public Hearings B… Oral evidence hearings commenced in Belfast.

01 Jan 2025 Hearings Continue Evidence hearings continue. · Source

Recommendations

106 shown (filtered)

Code	Recommendation	Addressed to	Response
R1	Implementation monitoring group The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. …	Department of Health NI	Response Pending	View →
R2	Public acceptance of recommendations within six months The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and …	Department of Health NI	Response Pending	View →
R3	Non-acceptance notification within three months With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which …	Northern Ireland Executive	Response Pending	View →
R4	Consultation before patient transfers Prior to the decision to move a service user to a different facility there must be discussion with the staff regularly caring …	Northern Ireland Executive	Response Pending	View →
R5	Named person for care plans Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this …	Northern Ireland Executive	Response Pending	View →
R6	Named person approval for transfers The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring …	Northern Ireland Executive	Response Pending	View →
R7	Independent living skills focus While patients remain in hospital pending resettlement, there should be a focus on enhancing their independent living skills, tailored to their physical …	Northern Ireland Executive	Response Pending	View →
R8	Medication audit and NICE compliance Medication should never be used simply to subdue people in the absence of other forms of treatment and good quality care. DoH …	Northern Ireland Executive	Response Pending	View →
R9	Integrated workforce plans Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in …	Northern Ireland Executive	Response Pending	View →
R10	Access to allied health professionals It is critical for the wellbeing of people with learning disabilities and autistic people that they are well supported by, and have …	Northern Ireland Executive	Response Pending	View →
R11	Meaningful daily activities Like anyone else, people with learning disabilities and autistic people require a variety of meaningful activities on a daily basis to enhance …	Northern Ireland Executive	Response Pending	View →
R12	Person-centred care plans with family involvement Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply …	Northern Ireland Executive	Response Pending	View →
R13	Full staff access to care plans All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.	Northern Ireland Executive	Response Pending	View →
R14	Restraint and seclusion observation records Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer …	Northern Ireland Executive	Response Pending	View →
R15	Independent care plan reviews Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and …	Northern Ireland Executive	Response Pending	View →
R16	Missed care incident reporting If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using …	Northern Ireland Executive	Response Pending	View →
R17	Co-production training Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As …	Department of Health NI	Response Pending	View →
R18	Co-production processes and clinical audit Specific processes rather than policies should be designed to ensure there is good communication with families and carers to ensure co-production takes …	Department of Health NI	Response Pending	View →
R19	Amend Quality Standards for shared decision-making The 2006 Quality Standards for Health and Social Care should be amended to require HSC organisations to provide all people with learning …	Department of Health NI	Response Pending	View →
R20	Independent advocacy for service users and families Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising …	Department of Health NI	Response Pending	View →
R21	Human rights officer in learning disability services All providers of learning disability services should appoint a human rights officer, as seen in Sheffield Health Partnership University NHS Foundation Trust …	Northern Ireland Executive	Response Pending	View →
R22	Easy Read documents All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.	Northern Ireland Executive	Response Pending	View →
R23	Regular property and finance compliance checks All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence …	Northern Ireland Executive	Response Pending	View →
R24	Clear records and disclosure policies Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with …	Northern Ireland Executive	Response Pending	View →
R25	Accessible financial records The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic …	Northern Ireland Executive	Response Pending	View →
R26	Six-monthly financial accounts to families Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) …	Northern Ireland Executive	Response Pending	View →
R27	RQIA assurance of property processes RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.		Response Pending	View →
R28	Restraint Reduction Network principles The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have …	Northern Ireland Executive	Response Pending	View →
R29	Psychology input to reduce restrictive practices All facilities providing residential services for people with learning disabilities and autistic people should provide sufficient psychology input for each patient, to …	Northern Ireland Executive	Response Pending	View →
R30	NED champion for restraint reduction HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors …	Northern Ireland Executive	Response Pending	View →
R31	Restraint education effectiveness metrics The effectiveness of the education programme for staff in relation to restraint reduction should be measured through defined data metrics. This is …	Northern Ireland Executive	Response Pending	View →
R32	Balanced performance measures including restrictive practices HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from …	Northern Ireland Executive	Response Pending	View →
R33	Statistical process control charts To ensure meaningful interpretation of these trends, all HSCTs should adopt statistical process control (SPC) charts, as developed by Walter Shewhart in …	Northern Ireland Executive	Response Pending	View →
R34	Debriefing policies for aggressive behaviour and restraint All HSCTs should develop two clear operational debriefing policies. The first should apply to both staff and people with learning disabilities and …	Northern Ireland Executive	Response Pending	View →
R35	Inpatient facilities on risk register Given the elevated risk of inappropriate use of restrictive practices with individuals with learning disabilities and/or autistic people, BHSCT and all HSCTs …	Northern Ireland Executive	Response Pending	View →
R36	Seclusion as extraordinary intervention with serious event audit Use of seclusion should be considered an extraordinary and exceptional intervention. Each intervention should be subject to a serious event audit, conducted …	Northern Ireland Executive	Response Pending	View →
R37	Human rights-based restrictive practices training Education and training on the use of restrictive practices should be grounded in human rights principles and the dedicated human rights specialist …	Northern Ireland Executive	Response Pending	View →
R38	Clear pathways for raising concerns People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for …	Northern Ireland Executive	Response Pending	View →
R39	Guidance on recording and presenting concerns People with learning disabilities and autistic people and their families should be provided with a short description of how best to record …	Northern Ireland Executive	Response Pending	View →
R40	Record all complaints in electronic system In HSCTs all complaints, regardless of whether they are resolved immediately at ward level, should be recorded in the Trust’s electronic complaints …	Northern Ireland Executive	Response Pending	View →
R41	Inform complainants of complaint management process Complainants should immediately be informed of how their complaint will be managed (locally or through the corporate complaints process) along with a …	Northern Ireland Executive	Response Pending	View →
R42	Regular updates on complaint progress Complainants must be regularly updated and informed of the progress of any investigation, including when the process concludes without a specific finding.	Northern Ireland Executive	Response Pending	View →
R43	Red-rated complaints shared with all NEDs All complaints managed at corporate level and rated as red (using the red, amber and green (RAG) rating matrix) should be shared …	Northern Ireland Executive	Response Pending	View →
R44	Proactive quality assurance beyond complaints Complaints alone are a poor indicator of quality of care, particularly in a vulnerable population such as those admitted to MAH. A …	Northern Ireland Executive	Response Pending	View →
R45	Incident trend analysis on board dashboards Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed …	Northern Ireland Executive	Response Pending	View →
R46	Lived experience feedback via external agency Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and …	Northern Ireland Executive	Response Pending	View →
R47	Quarterly family feedback via external agency The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency …	Northern Ireland Executive	Response Pending	View →
R48	Holistic safeguarding governance review HSCTs must review and improve governance of safeguarding to ensure that findings from different safeguarding investigations are considered holistically, synthesised and presented …	Northern Ireland Executive	Response Pending	View →
R49	CCTV in high-risk learning disability settings Hospital settings for people with learning disabilities and autistic people are very high-risk environments for abuse and poor practice, partly because those …	Northern Ireland Executive	Response Pending	View →
R50	CCTV guidelines for residential and day services Guidelines should be agreed in relation to providing CCTV systems in residential and day services where requested. Guidelines should be agreed by …	Northern Ireland Executive	Response Pending	View →
R51	CCTV in non-public areas only in best interests The installation of CCTV in non-public areas should be considered only where this will be in the best interests of the individual …	Northern Ireland Executive	Response Pending	View →
R52	CCTV policies agreed with staff residents and families Policies governing the use of CCTV should be agreed only after consultation with staff, residents and their families using the service.	Northern Ireland Executive	Response Pending	View →
R53	CCTV viewing circumstances Policies should include careful consideration of the circumstances in which the CCTV should be viewed; for example, that it should be viewed …	Northern Ireland Executive	Response Pending	View →
R54	Independent CCTV viewers Viewers of the CCTV should be independent of the setting, i.e. not involved in day-to-day care of the residents.	Northern Ireland Executive	Response Pending	View →
R55	External CCTV oversight Oversight of the CCTV analysis should sit outside the setting in which the CCTV is recording, and should include audits of referrals …	Northern Ireland Executive	Response Pending	View →
R56	CCTV referral guidance for police Policies should include clear guidance and definitions of behaviour and circumstances in which information should be passed to PSNI about possible offences.	Northern Ireland Executive	Response Pending	View →
R57	Regulator access to CCTV Policies should be clear about the circumstances in which a regulator, such as RQIA, could access the CCTV.	Northern Ireland Executive	Response Pending	View →
R58	CCTV for staff training consideration Those drafting the policy should consider whether CCTV could ever be used for staff training and, if so, how this would be …	Northern Ireland Executive	Response Pending	View →
R59	CCTV explained in accessible format All service users and their families should have the CCTV explained to them in easily understood language and with easy access materials, …	Northern Ireland Executive	Response Pending	View →
R60	Staff CCTV training All staff should receive training on the reasons for the use of CCTV and the processes for its analysis.	Northern Ireland Executive	Response Pending	View →
R61	Statutory adult safeguarding function Vulnerable children and adults are inherently more susceptible to abuse or neglect than other people. Adult safeguarding should be formally recognised as …	Department of Health NI	Response Pending	View →
R62	Monthly safeguarding dashboard Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status …	Northern Ireland Executive	Response Pending	View →
R63	Peer-on-peer abuse in safeguarding metrics Incidents of peer-on-peer abuse should be included in adult safeguarding metrics and included on a published safeguarding dashboard.	Northern Ireland Executive	Response Pending	View →
R64	Safeguarding dashboard with screening decisions The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to …	Department of Health NI	Response Pending	View →
R65	Common safeguarding investigation standards There should be common standards for the conduct of safeguarding investigations. These should be drafted and approved by the Northern Ireland Adult …	Department of Health NI	Response Pending	View →
R66	Quarterly safeguarding file audit A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with …	Northern Ireland Executive	Response Pending	View →
R67	Independent review of systemic abuse conditions Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An …	Northern Ireland Executive	Response Pending	View →
R68	Cumulative risk assessment across protection plans Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable …	Northern Ireland Executive	Response Pending	View →
R69	Needs-based staffing with acuity measures Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring …	Northern Ireland Executive	Response Pending	View →
R70	Mandatory monthly clinical supervision Clinical supervision (where individuals’ practice with individual patients is discussed) should be mandatory for all ward staff, including healthcare assistants, and should …	Northern Ireland Executive	Response Pending	View →
R71	Specialist training for healthcare assistants All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning …	Department of Health NI	Response Pending	View →
R72	Review supervision models for commissioned services SPPG must commission a review of the potential models for supervision of staff in private and third sector services commissioned by HSCTs, …	Department of Health NI	Response Pending	View →
R73	Band 4 associate practitioners Consideration should be given to enhancing the post of healthcare assistant by creating Band 4 associate practitioners in both hospital and community …	Northern Ireland Executive	Response Pending	View →
R74	Staffing review in safeguarding investigations Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.	Northern Ireland Executive	Response Pending	View →
R75	Executive Director of Clinical and Social Care Governance There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance …	Northern Ireland Executive	Response Pending	View →
R76	NED with clinical governance expertise NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical …	Northern Ireland Executive	Response Pending	View →
R77	Triennial Board governance reviews The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.	Department of Health NI	Response Pending	View →
R78	Audit committee implementation tracking HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months …	Northern Ireland Executive	Response Pending	View →
R79	Board member learning framework The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should …	Department of Health NI	Response Pending	View →
R80	NED for confidential staff reporting Consideration should be given to the creation of a role for a NED in each HSCT with the specific remit to receive …	Northern Ireland Executive	Response Pending	View →
R81	Expert clinical governance advisory function The DoH should establish an expert clinical/social governance advisory function to support providers.	Department of Health NI	Response Pending	View →
R82	Risk-based inspection prediction RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of …		Response Pending	View →
R83	RQIA use of CCTV in inspections The RQIA needs to reconsider whether to make use of CCTV when it is in operation in a service it is inspecting …		Response Pending	View →
R84	Learning disability service culture measure RQIA needs to consider adopting a measure of service culture specific to learning disability services for use in its inspections. Such measures …		Response Pending	View →
R85	RQIA communication with patients RQIA needs to spend proportionately more time talking to patients/residents, and its staff need to be trained in specific communication techniques such …		Response Pending	View →
R86	PCC information on quality of care standards The PCC should support service users/families and provide information on what constitutes good quality care for people with learning disabilities and autistic …		Response Pending	View →
R87	PCC awareness of statutory functions The PCC should take further steps to ensure that health service users, including carers and families of people with learning disabilities and …		Response Pending	View →
R88	PSNI investigation file review processes PSNI needs to improve its processes for the review of live investigation files, and have an effective escalation process when progress is …	Northern Ireland Executive	Response Pending	View →
R89	Review of prosecution system timeliness The Department of Justice should review the timeliness of the handling of each aspect of the prosecution system that has led to …	Northern Ireland Executive	Response Pending	View →
R90	Regional standing committee of service users and families A regional standing committee of people with learning disabilities and autistic people and their relatives should be established, to be consulted by …	Department of Health NI	Response Pending	View →
R91	Higher-funded resettlement team for complex needs There needs to be a recognition that those service users in Northern Ireland yet to be resettled (if there are any by …	Department of Health NI	Response Pending	View →
R92	Time frame and financial information for families Families should be provided by the relevant Trust with a time frame for resettlement and relevant financial information. Families should also be …	Northern Ireland Executive	Response Pending	View →
R93	Regional service map with vacancies There needs to be a clear regional view of all services available in the community, especially given the variety of services and …	Northern Ireland Executive	Response Pending	View →
R94	Continuing community support provision There will be a continuing need, which must be met, for new and ongoing community-based support for young people and adults with …	Northern Ireland Executive	Response Pending	View →
R95	Blue light protocol for at-risk registers HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in …	Northern Ireland Executive	Response Pending	View →
R96	Access to mainstream mental health services SPPG must ensure that people with learning disabilities and autistic people have access to mainstream (i.e. the same services that are available …	Department of Health NI	Response Pending	View →
R97	Funded access to primary care The SPPG must ensure that commissioning includes provision for people with learning disabilities and autistic people cared for in any facility to …	Department of Health NI	Response Pending	View →
R98	AHP and social care workforce recruitment The DoH must devise ways to recruit and retain more allied health professionals and social care staff in the community for autistic …	Department of Health NI	Response Pending	View →
R99	Key individual for resettlement communication Communication between the HSCTs and/or resettlement service providers and families and people with learning disabilities should be more open and transparent. Each …	Northern Ireland Executive	Response Pending	View →
R100	Person-centred day activities and supported employment Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and …	Northern Ireland Executive	Response Pending	View →
R101	Whole-system commissioning with cross-agency risk assessment Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole …	Department of Health NI	Response Pending	View →
R102	Centralised workforce intelligence function DoH should establish a comprehensive, centralised workforce intelligence function, similar to those in the rest of the UK, within 12 months of …	Department of Health NI	Response Pending	View →
R103	Public learning disability performance dashboard within 12 months A live dashboard of performance, quality and safety indicators within learning disabilities must be developed and made publicly available within 12 months …	Department of Health NI	Response Pending	View →
R104	Statutory duty of candour A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for …	Department of Health NI	Response Pending	View →
R105	Reverse burden for organisational failure to prevent harm Consideration should be given to a different approach to the prosecution of organisations for failing to prevent deliberate harm being caused by …	Department of Health NI	Response Pending	View →
R106	Redress working party for MAH victims In relation to direct redress, including consideration of financial compensation, we recommend that the DoH set up a small working party to …	Department of Health NI	Response Pending	View →

Costs

Total: £14,779,064

Period	Total	Inquiry legal	CP legal	Source
Sep 2025	£1,006,962	—	—	link
Sep 2025 (cum.)	£14,779,064	—	—	link
Mar 2025	£4,352,787	—	—	link
Mar 2024	£4,293,575	—	—	link
Mar 2023	£4,114,761	—	—	link
Mar 2022	£1,010,979	—	—	link