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
Source — 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
Publicly available evidence relating to this recommendation:
- The government announced the establishment of the Independent Patient Safety Investigation Service to work alongside existing bodies conducting external reviews (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- HSIB began operations in April 2017 and was succeeded by HSSIB as a statutory body from 1 October 2023 under Part 4 of the Health and Care Act 2022, providing a permanent framework for independent healthcare safety investigations (Health and Care Act 2022, c.31).
Response — verbatim from government
●Academy of Medical Royal Colleges
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).
Focus on quality: 43
Academy of Medical Royal Colleges · 16 Jul 2015 Written response →
Evidence trail — what's actually happened since
- 31 Dec 2015 Academy of Medical Royal Colleges issued guidance on external reviews of clinical services. Source →
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
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Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.