Assistance in deciding on prosecutions
Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013
Source — verbatim from the inquiry
●Inquiry recommendation
In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires individuals or organisations to be brought to account for their failings, the Health and Safety Executive should obtain expert advice, as is done in the field of healthcare litigation and fitness to practise proceedings.
Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- CQC employs specialist professional advisors (SPAs) across a range of clinical disciplines who provide expert advice during inspections and enforcement activities. CQC's enforcement policy (updated November 2023) sets out the approach to using specialist advice in cases involving potential criminal prosecution for ill-treatment or wilful neglect under sections 20-21 of the Criminal Justice and Courts Act 2015 (CQC enforcement policy, November 2023).
- The Crown Prosecution Service published legal guidance on the prosecution of offences of ill-treatment or wilful neglect (sections 20-21, Criminal Justice and Courts Act 2015), including guidance on evidential requirements and the use of expert evidence in healthcare cases (CPS legal guidance on ill-treatment and wilful neglect).
- HSE and CQC's memorandum of understanding provides for cooperation in cases that may engage both health and safety at work legislation and healthcare regulatory requirements, including arrangements for sharing expert advice (HSE/CQC MoU, 2014).
Response — verbatim from government
●Department of Health and Social Care
The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Department of Health and Social Care · 19 Nov 2013 Written response →
Evidence trail — what's actually happened since
- 30 Jun 2024 · NHS England - Learn from Patient Safety Events Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS). NRLS fully decommissioned 30 June 2024. LFPSE has broader coverage including primary care, uses machine learning for analysis and improved trend identification. View source → Confirmed Completed
- 1 Oct 2023 · Legislation - Health Services Safety Investigations Body HSSIB formally launched 1 October 2023 as independent statutory body under Health and Care Act 2022. Replaced HSIB (non-statutory, established 2016). Has statutory "safe space" protections, powers of entry, inspection and seizure. Conducts system-focused patient safety investigations. View source → Confirmed Completed
- 1 Oct 2023 · NHS England - Patient Safety Incident Response Framework Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework from Autumn 2023. Shifts from individual blame to system-based learning approaches. Mandatory for all NHS-funded secondary care providers. Part of NHS Patient Safety Strategy (July 2019). View source → Confirmed Completed
- 30 Sep 2023 · UK Government - Kark Review of FPPT Tom Kark QC reviewed the Fit and Proper Person Test in 2019 and found it essentially "does not ensure directors are fit for the post they hold, and does not stop the unfit from moving around the system." NHS England published updated FPPT Framework effective 30 September 2023 requiring standardised board-level assessments. View source → Reasonable Progress
- 6 Feb 2023 · Academic Review - Ten Years After Francis Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS. View source → Reasonable Progress
- 11 Feb 2015 · UK Government - Culture Change in the NHS Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year. View source → Good Progress
- 27 Nov 2014 · Legislation - Fit and Proper Person Requirement Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 5: Fit and Proper Person Requirement came into force November 2014. Requires providers to ensure directors meet fitness requirements including good character, qualifications, competence. CQC can require removal of directors. View source → Confirmed Completed
- 19 Nov 2013 · UK Government - Hard Truths Vol 1 & 2 Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted. View source → Good Progress
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.
How this page is built
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.