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Guidance for external service reviews

Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: Academy of Medical Royal Colleges

Government responseDepartment of Health and Social Care: Accepted (Jul 2015)

DeliveryDHSC and NHS England say completed (Feb 2026)Academy of Medical Royal Colleges says completed (Mar 2022)Department of Health and Social Care says in progress (Mar 2020)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. We recommend that systematic guidance be drawn up setting out an appropriate framework for external reviews and professional responsibilities in undertaking them. Action: the Academy of Medical Royal Colleges, the Royal College of Nursing, the Royal College of Midwives.

Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →

Published evidence summary

AI-generated evidence summary

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, following the Academy of Medical Royal Colleges publishing an updated framework for invited reviews in March 2022 (Academy of Medical Royal Colleges, Mar 2022; DHSC and NHS England, Feb 2026). They stated that the guidance provides operating principles for professional bodies conducting reviews across healthcare organisations and should improve the escalation of issues and disclosure to regulators (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

Government response

●Department of Health and Social Care · Accepted · 16 Jul 2015

Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015

109. We accept this recommendation, and there are actions in train, which go some way to meeting it. For example, the Serious Incident Framework published by NHS England and updated in March 2015, sets out details of when and how investigations – including independent investigations - should be undertaken. 110. As noted earlier, the Government are accepting the Public Administration Select Committee's recommendation to establish an independent patient safety investigation function for the NHS, and will be taking this forward in the coming months (the Independent Patient Safety Investigation Service). One of the tasks will be to work with stakeholders to consider how the new function will operate alongside and complement existing bodies that relate to NHS organisations and this will include organisations that may be carrying out other reviews (including professional and external reviews).

Response document: Learning not blaming: The government response to the Freedom to Speak Up consultation, the Public Administration Select Committee report 'Investigating Clinical Incidents in the NHS', and the Morecambe Bay Investigation

Site note: This is the Department of Health's response, "Learning not blaming" (Cm 9113, July 2015), to the Morecambe Bay Investigation and two other reports. The department has been the Department of Health and Social Care since January 2018, and the rows are filed under that name. Every word is the department's, including where it reports what another body has done or will do.

Site note: The recommendation is addressed to the Academy of Medical Royal Colleges; the passage is the Department of Health's account, not that body's.

Delivery

●DHSC and NHS England say completed · 27 Feb 2026

The Thirlwall Inquiry has noted action taken in response to this recommendation.

In response to this recommendation, the Academy of Royal Colleges published their updated invited review framework in March 2022. It provides a framework of operating principles for royal colleges and other professional bodies (reviewing organisations) when undertaking invited reviews on behalf of healthcare organisations across the UK. The framework should lead to an improvement in the disclosure of reports to CQC and escalation of issues.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 23.2 No. 41, PDF page 655-656.

●Academy of Medical Royal Colleges says completed · 1 Mar 2022

This document replaces the earlier version published in 2016. It provides a framework
of operating principles for royal colleges and other professional bodies (reviewing
organisations) when undertaking invited reviews on behalf of healthcare organisations
across the UK.

From: Managing invited reviews within healthcare: a framework of operating principles

Site note: The Academy of Medical Royal Colleges' framework for invited reviews, whose Background quotes this recommendation. The document gives only its month (March 2022, "Revised February 2022"), so the row is dated the first of that month. It replaces a first version published in 2016, which the site has not read.

●Department of Health and Social Care says in progress · 2 Mar 2020

NHS England and NHS Improvement have agreed to establish an advisory function for independent reviews which they sponsor, commission or oversee. This will advise on the establishment and best practice management of these types of reviews.

From: NHS Trusts: Reviews (written question UIN 20428)

Site note: Written answer of 2 March 2020 by Nadine Dorries for the Department of Health and Social Care. The question cites the Morecambe Bay Investigation report and asks what has been done on this recommendation. The recommendation is addressed to the Academy of Medical Royal Colleges, the Royal College of Nursing and the Royal College of Midwives; this is the Department's answer, not theirs.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 15 May 2024

Department of Health response (July 2015):

Accepted in principle.

“… there are actions in train, which go some way to meeting it. For example, the Serious Incident Framework published by NHS England and updated in March 2015, sets out details of when and how investigations – including independent investigations - should be undertaken.

As noted earlier, the Government are accepting the Public Administration Select Committee’s recommendation to establish an independent patient safety investigation function for the NHS … we will be taking this forward … One of the tasks will be …to consider how the new function will operate alongside and complement existing bodies that relate to NHS … organisations that may be carrying out other reviews (including professional and external reviews).” (p. 95)

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 20.2 No. 41, PDF page 620-621.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.